MEDICARE: KENSLEIGH HOGAN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6721	NC

General Provider Information

NPI Number	:	1306634332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENSLEIGH HOGAN PSYD

Provider Business Mailing Address
First Line	:	2813 COLTSGATE RD STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3585
Country	:	US
Telephone Number	:	704-362-3123
Fax Number	:

Provider Business Practice Location Address
First Line	:	2813 COLTSGATE RD STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3585
Country	:	US
Telephone Number	:	704-362-3121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2025
Last Update Date	:	06/03/2025

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