Provider Demographics
NPI:1760174783
Name:FOTHERGILL, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FOTHERGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-1691
Mailing Address - Country:US
Mailing Address - Phone:202-465-1818
Mailing Address - Fax:
Practice Address - Street 1:3600 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-1691
Practice Address - Country:US
Practice Address - Phone:202-465-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG20001355104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker