Provider Demographics
NPI:1891865804
Name:FOGT, MONA MARBETH (LCSW ACP)
Entity Type:Individual
Prefix:MRS
First Name:MONA
Middle Name:MARBETH
Last Name:FOGT
Suffix:
Gender:F
Credentials:LCSW ACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 CAMPBELL RD
Mailing Address - Street 2:BLDG C
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055
Mailing Address - Country:US
Mailing Address - Phone:713-973-8245
Mailing Address - Fax:713-973-0545
Practice Address - Street 1:1313 CAMPBELL RD
Practice Address - Street 2:BLDG C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055
Practice Address - Country:US
Practice Address - Phone:713-973-8245
Practice Address - Fax:713-973-0545
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX014431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1391007321316OtherAIS
TXWS0004452Medicaid
TXSW00S2106Medicare ID - Type Unspecified
TXWS0004452Medicaid