Provider Demographics
NPI:1316955081
Name:KOGAN, IDA I (LMSW)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:I
Last Name:KOGAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27875 BERRYWOOD LN
Mailing Address - Street 2:#88
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4057
Mailing Address - Country:US
Mailing Address - Phone:248-539-0238
Mailing Address - Fax:
Practice Address - Street 1:27875 BERRYWOOD LN
Practice Address - Street 2:#88
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4057
Practice Address - Country:US
Practice Address - Phone:248-539-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010744281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI085176681 6OtherAARP
MI6801074428OtherLMSW
MI18883543OtherSENIOR PLUS