Provider Demographics
NPI:1922619931
Name:FOGLEMAN, STEPHEN D (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:FOGLEMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3157 CAINTAL CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-1804
Mailing Address - Country:US
Mailing Address - Phone:828-553-3175
Mailing Address - Fax:
Practice Address - Street 1:814 JUNIPER ST NE STE 201
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1300
Practice Address - Country:US
Practice Address - Phone:404-254-6816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004411103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist