Provider Demographics
NPI:1548737448
Name:FOGLEMAN, MARK ALEXANDER (BCBA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALEXANDER
Last Name:FOGLEMAN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 EASTOVER RIDGE DR APT 333
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1481
Mailing Address - Country:US
Mailing Address - Phone:336-261-8649
Mailing Address - Fax:
Practice Address - Street 1:3000 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5226
Practice Address - Country:US
Practice Address - Phone:336-261-8649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NC12149365103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician