1770650442 NPI number — CANDICE R HOGDEN

Table of content: (NPI 1770650442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770650442 NPI number — CANDICE R HOGDEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANDICE R HOGDEN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770650442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5016 N UNIVERSITY
Provider Second Line Business Mailing Address:
CHRISTUS LIGHT COUNSELING STE 109
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-4763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-692-1220
Provider Business Mailing Address Fax Number:
309-692-1222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5016 N UNIVERSITY
Provider Second Line Business Practice Location Address:
CHRISTUS LIGHT COUNSELING STE 109
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-4763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-692-1220
Provider Business Practice Location Address Fax Number:
309-692-1222
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOGDEN
Authorized Official First Name:
CANDICE
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
DIRECTOR COUNSELOR
Authorized Official Telephone Number:
309-692-1220

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  2243-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101Y00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103515 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 236610 . This is a "VALUE OPTIONS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 357929 . This is a "MHN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 39281200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 469922 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7230084 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 07232101 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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