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General NPI Number Information
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NPI Number | 1003380049
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Entity Type | Individual
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Provider Name | KIMBERLY VERMILLION FOGARTY JD, MA, BC-TMH
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Gender | Female
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Dates
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Enumeration Date | 01/13/2019
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Last Update Date | 01/13/2019
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Provider Practice Location Address
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Address Line | 580 BROADWAY ST STE 208
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City | LAGUNA BEACH
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State | CA
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Zip | 92651-4311
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Country | US
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Telephone | 949-424-9755
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Fax | 949-488-0344
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Provider Business Mailing Address
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Address Line | 8 PACIFICO
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City | LAGUNA NIGUEL
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State | CA
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Zip | 92677-4242
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Country | US
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Telephone | 949-422-5885
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 1600014
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 89459
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License Number State | CA
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