Basic Information
| Provider Information | |||||||||
| NPI: | 1194173666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOGARTY | ||||||||
| FirstName: | KIRSTEN | ||||||||
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| Credential: | P.T D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 N LITCHFIELD RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853957804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239355505 | ||||||||
| FaxNumber: | 6239355551 | ||||||||
| Practice Location | |||||||||
| Address1: | 3035 S ELLSWORTH RD | ||||||||
| Address2: | BLDG 4 STE 128 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852122160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803576500 | ||||||||
| FaxNumber: | 4803576515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12190 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.