Provider Demographics
NPI:1922463660
Name:KIMBERLY V. FOGARTY, LICENSED MARRIAGE & FAMILY THERAPY, PC
Entity Type:Organization
Organization Name:KIMBERLY V. FOGARTY, LICENSED MARRIAGE & FAMILY THERAPY, PC
Other - Org Name:INNERSELF TELETHERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:VERMILLION
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:JD, LMFT, BC-TMH
Authorized Official - Phone:949-424-9755
Mailing Address - Street 1:580 BROADWAY ST STE 208
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-4311
Mailing Address - Country:US
Mailing Address - Phone:949-424-9755
Mailing Address - Fax:949-488-0344
Practice Address - Street 1:8 PACIFICO
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4242
Practice Address - Country:US
Practice Address - Phone:949-424-9755
Practice Address - Fax:949-488-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-23
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT89459106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty