Provider Demographics
NPI:1194173666
Name:FOGARTY, KIRSTEN (PT DPT)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 N LITCHFIELD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-7804
Mailing Address - Country:US
Mailing Address - Phone:623-935-5505
Mailing Address - Fax:623-935-5551
Practice Address - Street 1:3035 S ELLSWORTH RD
Practice Address - Street 2:BLDG 4 STE 128
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2160
Practice Address - Country:US
Practice Address - Phone:480-357-6500
Practice Address - Fax:480-357-6515
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist