Provider Demographics
NPI:1871363481
Name:HOGAN, RICO MONTINEZE (LCSW)
Entity type:Individual
Prefix:
First Name:RICO
Middle Name:MONTINEZE
Last Name:HOGAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 MURA DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-4819
Mailing Address - Country:US
Mailing Address - Phone:706-589-2883
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 327, CENTRAL HOSPITAL RD.
Practice Address - Street 2:
Practice Address - City:FORT EISENHOWER
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-8651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0161331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty