Provider Demographics
NPI:1700162971
Name:FOGERTY MUSIC THERAPY, LLC
Entity Type:Organization
Organization Name:FOGERTY MUSIC THERAPY, LLC
Other - Org Name:FOGERTY MUSIC THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MM, MT-BC
Authorized Official - Phone:812-340-9269
Mailing Address - Street 1:4729 SHALIMAR DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-1048
Mailing Address - Country:US
Mailing Address - Phone:812-340-9269
Mailing Address - Fax:
Practice Address - Street 1:515 S WOODSCREST DR STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5303
Practice Address - Country:US
Practice Address - Phone:812-340-9269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Single Specialty