Provider Demographics
NPI:1689962466
Name:FOGEL, BETH JOY (MSW, CSW)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:JOY
Last Name:FOGEL
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E RED SHADOW CIR
Mailing Address - Street 2:P.O. BOX 285
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-3642
Mailing Address - Country:US
Mailing Address - Phone:435-899-9115
Mailing Address - Fax:916-644-8872
Practice Address - Street 1:110 E RED SHADOW CIR
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3642
Practice Address - Country:US
Practice Address - Phone:435-899-9115
Practice Address - Fax:916-644-8872
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5418941-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT274337128OtherTAX I.D.