Provider Demographics
NPI:1033121124
Name:FOGEL, KENNETH ADAM (PSY D)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ADAM
Last Name:FOGEL
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:ADAM
Other - Last Name:FOGEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:118 N CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-384-5679
Mailing Address - Fax:
Practice Address - Street 1:200 S FRONTAGE RD STE 324
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6953
Practice Address - Country:US
Practice Address - Phone:847-347-0491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006356103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical