Healthcare Provider Details

I. General information

NPI: 1396251336
Provider Name (Legal Business Name): MARTIN EUGENE HOGAN LPC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD STE 200
BROWN DEER WI
53209-1220
US

IV. Provider business mailing address

5325 W BURLEIGH ST
MILWAUKEE WI
53210-1623
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2170
  • Fax:
Mailing address:
  • Phone: 414-810-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18445-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3898-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: