Provider Demographics
NPI:1053939983
Name:FOGLE, ANTWON ONEIL (MSW, LCSWA)
Entity type:Individual
Prefix:MR
First Name:ANTWON
Middle Name:ONEIL
Last Name:FOGLE
Suffix:
Gender:M
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 BROOMSTRAW CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-3968
Mailing Address - Country:US
Mailing Address - Phone:919-358-8127
Mailing Address - Fax:
Practice Address - Street 1:3824 BARRETT DR STE 105
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7220
Practice Address - Country:US
Practice Address - Phone:919-790-7775
Practice Address - Fax:919-790-9755
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO145141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical