Provider Demographics
NPI:1972849289
Name:CHRISTIE-FOGG, KAILEAH (LCSW)
Entity Type:Individual
Prefix:
First Name:KAILEAH
Middle Name:
Last Name:CHRISTIE-FOGG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KAILEAH
Other - Middle Name:
Other - Last Name:CHRISTIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:481 GOLD STAR HWY
Mailing Address - Street 2:301
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6702
Mailing Address - Country:US
Mailing Address - Phone:860-287-6393
Mailing Address - Fax:
Practice Address - Street 1:481 GOLD STAR HWY
Practice Address - Street 2:301
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6702
Practice Address - Country:US
Practice Address - Phone:860-287-6393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-14
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8828104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker