Provider Demographics
NPI:1932937729
Name:FOGLE, MADELYN
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:FOGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12229 W THOMAS CT
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9435
Mailing Address - Country:US
Mailing Address - Phone:708-945-9662
Mailing Address - Fax:
Practice Address - Street 1:66 MILLER DR STE 102
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-5144
Practice Address - Country:US
Practice Address - Phone:630-907-9165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-339499106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician