Provider Demographics
NPI:1104800960
Name:FOGAL, KENNETH GERARD (MS VP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GERARD
Last Name:FOGAL
Suffix:
Gender:M
Credentials:MS VP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1691
Mailing Address - Country:US
Mailing Address - Phone:218-546-8375
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:318 E MAIN ST
Practice Address - Street 2:CENTRAL LAKES MEDICAL CLINIC ,PA
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1691
Practice Address - Country:US
Practice Address - Phone:218-546-8375
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0270103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist