Basic Information
| Provider Information | |||||||||
| NPI: | 1346402245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOGLE | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW, CCM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5669 GOLD CREEK DR | ||||||||
| Address2: | |||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945525443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105029215 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4601 DALE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097355000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS 19284 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.