Provider Demographics
NPI:1609322080
Name:FOGARTY, STACY (LSSP, LPC-I)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:LSSP, LPC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 E CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4604
Mailing Address - Country:US
Mailing Address - Phone:512-643-7473
Mailing Address - Fax:
Practice Address - Street 1:2324 E CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4604
Practice Address - Country:US
Practice Address - Phone:512-643-7473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health