Provider Demographics
NPI:1063411452
Name:FOGLE, VERNELL KENNEDY (PHD)
Entity type:Individual
Prefix:DR
First Name:VERNELL
Middle Name:KENNEDY
Last Name:FOGLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1702
Mailing Address - Country:US
Mailing Address - Phone:803-255-0852
Mailing Address - Fax:803-312-9983
Practice Address - Street 1:1107 BELLEVIEW ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1810
Practice Address - Country:US
Practice Address - Phone:803-381-3171
Practice Address - Fax:803-312-9983
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0373Medicaid