Provider Demographics
NPI:1982769162
Name:FOGARTY, LORI L (LICSW)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DANGELIS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-3510
Mailing Address - Country:US
Mailing Address - Phone:401-331-1350
Mailing Address - Fax:401-277-3366
Practice Address - Street 1:17 ASHTON PARK WAY STE 202
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-4827
Practice Address - Country:US
Practice Address - Phone:401-654-8957
Practice Address - Fax:401-563-9799
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW015831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILF43459Medicaid