Provider Demographics
NPI:1558160242
Name:FOGARTY, CORINNE (RBT)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:FOGARTY
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-7007
Mailing Address - Country:US
Mailing Address - Phone:417-629-6595
Mailing Address - Fax:
Practice Address - Street 1:5604 N ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64119-2327
Practice Address - Country:US
Practice Address - Phone:816-533-5057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-24-333626106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician