Provider Demographics
NPI:1609049030
Name:FOGARTY, MELISSA LINDA (MA, LMHC)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LINDA
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:MA, LMHC
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 546
Mailing Address - Street 2:
Mailing Address - City:VAUGHN
Mailing Address - State:WA
Mailing Address - Zip Code:98394-0546
Mailing Address - Country:US
Mailing Address - Phone:253-514-5422
Mailing Address - Fax:253-884-2632
Practice Address - Street 1:8903 KEY PENINSULA HWY N
Practice Address - Street 2:
Practice Address - City:LAKEBAY
Practice Address - State:WA
Practice Address - Zip Code:98349-9326
Practice Address - Country:US
Practice Address - Phone:253-514-5422
Practice Address - Fax:253-884-2632
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006364101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health