Provider Demographics
NPI:1255700134
Name:FOGG, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FOGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 NW BETHANY BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5208
Practice Address - Country:US
Practice Address - Phone:503-567-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR0000WDBCHMedicare PIN