Healthcare Provider Details

I. General information

NPI: 1366455511
Provider Name (Legal Business Name): JOANNA H FOGG-WABERSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RETREAT AVE INSTITUTE OF LIVING
HARTFORD CT
06106-3309
US

IV. Provider business mailing address

PO BOX 40,000 DEPT 634 HARTFORD HOSPITAL PROFESSIONAL SERVICES
HARTFORD CT
06151-0634
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-7189
  • Fax:
Mailing address:
  • Phone: 860-545-7602
  • Fax: 860-545-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number028417
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number028417
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: