Provider Demographics
NPI:1831214485
Name:FOGG, CHASIDY COLLEEN SUMMER (MA LLP LPC)
Entity type:Individual
Prefix:MISS
First Name:CHASIDY
Middle Name:COLLEEN SUMMER
Last Name:FOGG
Suffix:
Gender:F
Credentials:MA LLP LPC
Other - Prefix:
Other - First Name:CHASIDY
Other - Middle Name:COLLEEN SUMMER
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LLP LPC
Mailing Address - Street 1:4287 RACE RD
Mailing Address - Street 2:
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251-9446
Mailing Address - Country:US
Mailing Address - Phone:517-712-7204
Mailing Address - Fax:517-796-4561
Practice Address - Street 1:4287 RACE RD
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251-9446
Practice Address - Country:US
Practice Address - Phone:517-712-7204
Practice Address - Fax:517-796-4561
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010112101YP2500X
MI6301013308103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional