Provider Demographics
NPI:1134697980
Name:FOGARTY, LAURAINE MILDRED (RADT-1)
Entity Type:Individual
Prefix:MRS
First Name:LAURAINE
Middle Name:MILDRED
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 GIANELLI ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4658
Mailing Address - Country:US
Mailing Address - Phone:510-329-6153
Mailing Address - Fax:209-834-8674
Practice Address - Street 1:580 GIANELLI ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4658
Practice Address - Country:US
Practice Address - Phone:510-329-6153
Practice Address - Fax:209-834-8674
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1255740617101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty