Provider Demographics
NPI:1700367836
Name:FOGARTY, ALLISON MARIE (PSYCHOLOGY MA)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:MARIE
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:PSYCHOLOGY MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 PIER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4548
Mailing Address - Country:US
Mailing Address - Phone:818-792-2095
Mailing Address - Fax:310-317-7558
Practice Address - Street 1:15305 RAYEN ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5117
Practice Address - Country:US
Practice Address - Phone:818-892-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE