Provider Demographics
NPI:1992770242
Name:POGUE, WILLIAM JACK (MA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JACK
Last Name:POGUE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5835
Mailing Address - Country:US
Mailing Address - Phone:505-325-5321
Mailing Address - Fax:505-325-6453
Practice Address - Street 1:313 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5835
Practice Address - Country:US
Practice Address - Phone:505-325-5321
Practice Address - Fax:505-325-6453
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1607101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850447796OtherSAN JUAN IPA
NM98965OtherVALUE OPTIONS
NM362OtherMESA MENTAL HEALTH
NM98965Medicaid
NM23788OtherPRESBYTERIAN HEALTH CARE
NM65613OtherCIGNA HEALTH CARE
NMR64SOtherBLUE CROSS BLUE SHIELD
NM15483OtherLOVELACE HEALTH CARE
NMVNM000690TMedicaid