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General NPI Number Information
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NPI Number | 1033121124
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Entity Type | Individual
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Provider Name | KENNETH ADAM FOGEL PSY D
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Gender | Male
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Dates
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Enumeration Date | 08/13/2006
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Last Update Date | 01/08/2021
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Provider Practice Location Address
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Address Line | 200 S FRONTAGE RD STE 324
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City | BURR RIDGE
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State | IL
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Zip | 60527-6953
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Country | US
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Telephone | 847-347-0491
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Fax |
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Provider Business Mailing Address
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Address Line | 118 N CHESTER AVE
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City | PARK RIDGE
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State | IL
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Zip | 60068
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Country | US
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Telephone | 847-384-5679
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071006356
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License Number State | IL
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