Provider Demographics
NPI:1407148414
Name:BROWN FOGLE, ALISA DENISE (BS)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:DENISE
Last Name:BROWN FOGLE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10421 WESTOVER AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-5664
Mailing Address - Country:US
Mailing Address - Phone:405-830-0279
Mailing Address - Fax:
Practice Address - Street 1:10421 WESTOVER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-5664
Practice Address - Country:US
Practice Address - Phone:405-830-0279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health