Provider Demographics
NPI:1558030775
Name:FOGLE, KIMBERLY (CCC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FOGLE
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-4719
Mailing Address - Country:US
Mailing Address - Phone:972-968-1425
Mailing Address - Fax:972-968-1410
Practice Address - Street 1:2115 RAINTREE DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-4719
Practice Address - Country:US
Practice Address - Phone:972-968-1425
Practice Address - Fax:972-968-1410
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111521235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty