Provider Demographics
NPI:1104924711
Name:FOTHERGILL, WILLIAM (MA, MSW, LPC)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:FOTHERGILL
Suffix:
Gender:M
Credentials:MA, MSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1702
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06144-1702
Mailing Address - Country:US
Mailing Address - Phone:860-977-3575
Mailing Address - Fax:860-296-5939
Practice Address - Street 1:864 WETHERSFIELD AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-3184
Practice Address - Country:US
Practice Address - Phone:860-977-3575
Practice Address - Fax:860-296-5939
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000533101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker