Provider Demographics
NPI:1215566385
Name:FOGG, SHERRIE NICOLE (LCAS-A)
Entity Type:Individual
Prefix:
First Name:SHERRIE
Middle Name:NICOLE
Last Name:FOGG
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-4691
Mailing Address - Country:US
Mailing Address - Phone:336-655-6946
Mailing Address - Fax:
Practice Address - Street 1:215 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-4691
Practice Address - Country:US
Practice Address - Phone:336-655-6946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-26053101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)