Provider Demographics
NPI:1417976697
Name:FOGEL, DENISE (PSYD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:FOGEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 S MAIN ST
Mailing Address - Street 2:THE CARRIAGE HOUSE
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4226
Mailing Address - Country:US
Mailing Address - Phone:860-803-6707
Mailing Address - Fax:877-310-0731
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:THE CARRIAGE HOUSE
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4226
Practice Address - Country:US
Practice Address - Phone:860-803-6707
Practice Address - Fax:877-310-0731
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002558103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001724 (C00814)Medicare PIN