Provider Demographics
NPI:1356772446
Name:FOGG, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
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 1:12511 SW 68TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8510
Mailing Address - Country:US
Mailing Address - Phone:503-719-2420
Mailing Address - Fax:
Practice Address - Street 1:12511 SW 68TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8510
Practice Address - Country:US
Practice Address - Phone:503-719-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor