Healthcare Provider Details

I. General information

NPI: 1396075602
Provider Name (Legal Business Name): PEGGY KAY FORTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1392 MAPLE DR
FAIRVIEW MI
48621-8703
US

IV. Provider business mailing address

1392 MAPLE DR
FAIRVIEW MI
48621-8703
US

V. Phone/Fax

Practice location:
  • Phone: 989-848-5644
  • Fax: 989-848-7411
Mailing address:
  • Phone: 989-848-5644
  • Fax: 989-848-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010385
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: