Provider Demographics
NPI:1003380049
Name:FOGARTY, KIMBERLY VERMILLION (JD, MA, BC-TMH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:VERMILLION
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:JD, MA, BC-TMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 PACIFICO
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4242
Mailing Address - Country:US
Mailing Address - Phone:949-422-5885
Mailing Address - Fax:
Practice Address - Street 1:580 BROADWAY ST STE 208
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-4311
Practice Address - Country:US
Practice Address - Phone:949-424-9755
Practice Address - Fax:949-488-0344
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-13
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1600014106H00000X
CA89459106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist