Healthcare Provider Details

I. General information

NPI: 1912842774
Provider Name (Legal Business Name): MADELYNN LACI FOUGERE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 38TH AVE N # 391
MYRTLE BEACH SC
29577-1313
US

IV. Provider business mailing address

3237 SADDLEWOOD CIR
MYRTLE BEACH SC
29579-4346
US

V. Phone/Fax

Practice location:
  • Phone: 720-600-8434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: