Healthcare Provider Details

I. General information

NPI: 1700162971
Provider Name (Legal Business Name): FOGERTY MUSIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S WOODSCREST DR STE B
BLOOMINGTON IN
47401-5303
US

IV. Provider business mailing address

4729 SHALIMAR DR
COLUMBIA SC
29206-1048
US

V. Phone/Fax

Practice location:
  • Phone: 812-340-9269
  • Fax:
Mailing address:
  • Phone: 812-340-9269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name: JONNETTA FOGERTY
Title or Position: OWNER, DIRECTOR
Credential: MM, MT-BC
Phone: 812-340-9269