Provider Demographics
NPI:1114323334
Name:FOGARTY, MATTHEW (CC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2582 NORTHSHORE RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9477
Mailing Address - Country:US
Mailing Address - Phone:202-810-5360
Mailing Address - Fax:
Practice Address - Street 1:2582 NORTHSHORE RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9477
Practice Address - Country:US
Practice Address - Phone:202-810-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-16
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61151236101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health