Provider Demographics
NPI:1891751624
Name:FOGLE, JOSEPH EDWIN (PHD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EDWIN
Last Name:FOGLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:E
Other - Last Name:FOGLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:9412 WINDY KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-7560
Mailing Address - Country:US
Mailing Address - Phone:214-348-2849
Mailing Address - Fax:
Practice Address - Street 1:7557 RAMBLER RD
Practice Address - Street 2:SUITE 711
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4142
Practice Address - Country:US
Practice Address - Phone:214-363-8391
Practice Address - Fax:214-363-8316
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24389103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J05POtherBLUE CROSS/BLUE SHIELD
TX00J05PMedicare ID - Type Unspecified