Healthcare Provider Details

I. General information

NPI: 1548737448
Provider Name (Legal Business Name): MARK ALEXANDER FOGLEMAN BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 LATROBE DR
CHARLOTTE NC
28211-5226
US

IV. Provider business mailing address

3306 EASTOVER RIDGE DR APT 333
CHARLOTTE NC
28211-1481
US

V. Phone/Fax

Practice location:
  • Phone: 336-261-8649
  • Fax:
Mailing address:
  • Phone: 336-261-8649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12149365
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: