Provider Demographics
NPI:1740704741
Name:FOGG, MIRANDA LYNN
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
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 1:112 MAIN RD.
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:244 WESTFIELD RD
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040
Practice Address - Country:US
Practice Address - Phone:413-534-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician