Provider Demographics
NPI:1891085767
Name:FOGARTY, JAMES ADRIAN (EDD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ADRIAN
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 S. PRAIRIE ST SUITE A
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072
Mailing Address - Country:US
Mailing Address - Phone:815-624-8383
Mailing Address - Fax:815-624-8383
Practice Address - Street 1:122 S. PRAIRIE ST. SUITE A
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072
Practice Address - Country:US
Practice Address - Phone:815-624-8383
Practice Address - Fax:815-624-8383
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.003659103TC0700X
IL071-003-659103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical