Provider Demographics
NPI:1215035357
Name:FOGAL, TAMMIE (MA, LLP)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
Last Name:FOGAL
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 TUSCOLA
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6995
Mailing Address - Country:US
Mailing Address - Phone:989-895-0788
Mailing Address - Fax:
Practice Address - Street 1:114 TUSCOLA
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6995
Practice Address - Country:US
Practice Address - Phone:989-895-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012366103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI042659OtherCIGNA
MA1014496OtherMCLAREN
MI042659OtherVALUE OPTIONS