Healthcare Provider Details

I. General information

NPI: 1639483597
Provider Name (Legal Business Name): TIM HOGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PONDEROSA AVE NE
ALBUQUERQUE NM
87110-1216
US

IV. Provider business mailing address

1764 LEE LOOP NE
RIO RANCHO NM
87144-5472
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-8982
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: