Provider Demographics
NPI:1932731429
Name:FOGARTY, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:FOGARTY
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 1:1424 MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:IL
Mailing Address - Zip Code:61957-1010
Mailing Address - Country:US
Mailing Address - Phone:217-459-2636
Mailing Address - Fax:
Practice Address - Street 1:1424 MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:IL
Practice Address - Zip Code:61957-1010
Practice Address - Country:US
Practice Address - Phone:217-459-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool