Provider Demographics
NPI:1316060296
Name:HOGENSON, GEORGE BJORGO (PHD LCSW)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:BJORGO
Last Name:HOGENSON
Suffix:
Gender:M
Credentials:PHD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 N MARION ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1632
Mailing Address - Country:US
Mailing Address - Phone:312-543-6464
Mailing Address - Fax:
Practice Address - Street 1:646 N MARION ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1632
Practice Address - Country:US
Practice Address - Phone:312-543-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-04845Medicare UPIN