Provider Demographics
NPI:1225087455
Name:FORTGANG, ROBERT J (MA, LCMHC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:FORTGANG
Suffix:
Gender:M
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03256-0266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 PARK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3030
Practice Address - Country:US
Practice Address - Phone:603-387-4927
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000243101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010554Medicaid