Basic Information
| Provider Information | |||||||||
| NPI: | 1902119589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOGAN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067043424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 006294 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | OPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UNITED HEALTHCARE/UBH WELLMORE GRP/FACILITY | OTHER | 475346 PENDING | 01 | CT | MHN TRICARENORTH | OTHER | 060669107 | 01 | CT | CONNECTICARE/UBH WELLMORE GRP/FACILITY | OTHER | PENDING | 05 | CT | MEDICAID | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 475346 PENDING | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | 12149987 | 01 | CT | CAQH | OTHER | 060669107 | 01 | CT | AETNA BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | OXFORD HEALTH/FREEDOM PLAN-UBH WELLMORE GRP/FACILITY | OTHER |