Basic Information
| Provider Information | |||||||||
| NPI: | 1760580856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOGAN | ||||||||
| FirstName: | SHELTON | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | SOCIAL WORKER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 ARMOR LN | ||||||||
| Address2: | |||||||||
| City: | NORTH EASTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023562676 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 BELMONT ST | ||||||||
| Address2: | BROCKTON VETERANS HOSPITAL | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085834500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 106919 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 106929 | 01 | MA | LICENSE INDEPENDENT SOCAI | OTHER |