Provider Demographics
NPI:1124093984
Name:HOGAN, MARY MAURICELLA (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MAURICELLA
Last Name:HOGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MAURICELLA
Other - Last Name:LAUCHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-6830
Mailing Address - Country:US
Mailing Address - Phone:918-540-7433
Mailing Address - Fax:918-540-7474
Practice Address - Street 1:200 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6830
Practice Address - Country:US
Practice Address - Phone:918-540-7433
Practice Address - Fax:918-540-7474
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q61061Medicare UPIN