Provider Demographics
NPI:1477889111
Name:FOGG, SUSAN BUSKILL (LPC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BUSKILL
Last Name:FOGG
Suffix:
Gender:F
Credentials:LPC
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 683
Mailing Address - Street 2:
Mailing Address - City:POUNDING MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24637-0683
Mailing Address - Country:US
Mailing Address - Phone:276-210-4618
Mailing Address - Fax:
Practice Address - Street 1:19873 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614
Practice Address - Country:US
Practice Address - Phone:276-210-4618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-31
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004695101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12029478Medicaid