Provider Demographics
NPI:1346402245
Name:FOGLE, GEORGE ALLAN (LCSW, CCM)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:ALLAN
Last Name:FOGLE
Suffix:
Gender:M
Credentials:LCSW, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5669 GOLD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94552-5443
Mailing Address - Country:US
Mailing Address - Phone:510-502-9215
Mailing Address - Fax:
Practice Address - Street 1:4601 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9718
Practice Address - Country:US
Practice Address - Phone:209-735-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 192841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical