Provider Demographics
NPI:1326889742
Name:HOGAN, JUSTIN (LMT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:HOGAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-7347
Mailing Address - Country:US
Mailing Address - Phone:706-597-0059
Mailing Address - Fax:706-597-0059
Practice Address - Street 1:1258 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-7347
Practice Address - Country:US
Practice Address - Phone:706-597-0059
Practice Address - Fax:706-597-0059
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005828225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist