Basic Information
| Provider Information | |||||||||
| NPI: | 1366455511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOGG-WABERSKI | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40,000 DEPT 634 | ||||||||
| Address2: | HARTFORD HOSPITAL PROFESSIONAL SERVICES | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061510634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605457602 | ||||||||
| FaxNumber: | 8605457601 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 RETREAT AVE | ||||||||
| Address2: | INSTITUTE OF LIVING | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061063309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605457189 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | 028417 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0800X | 028417 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 001284173 | 05 | CT | MEDICAID |