Provider Demographics
NPI:1922550334
Name:FOGLEY, REBECCA LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LYNN
Last Name:FOGLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2716
Mailing Address - Country:US
Mailing Address - Phone:336-725-3999
Mailing Address - Fax:336-725-7720
Practice Address - Street 1:640 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2716
Practice Address - Country:US
Practice Address - Phone:336-725-3999
Practice Address - Fax:336-725-7720
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical