MEDICARE: GREGORY KOGUC LPC

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	101YM0800X	Mental Health Counselor	37PC00309400	NJ

General Provider Information

NPI Number	:	1669534996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY KOGUC LPC

Provider Business Mailing Address
First Line	:	PO BOX 1086
Second Line	:
City	:	PLEASANTVILLE
State	:	NJ
Zip	:	08232-6086
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 N ALBANY AVE
Second Line	:	ATLANTIC CITY TEEN CENTER AT ATLANTIC CITY HIGH SCHOOL
City	:	ATLANTIC CITY
State	:	NJ
Zip	:	08401-1208
Country	:	US
Telephone Number	:	609-645-7601
Fax Number	:

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/08/2007

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