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General NPI Number Information
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NPI Number | 1265044499
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Entity Type | Organization
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Legal Business Name | FOGARTY WELLNESS LLC
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Dates
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Enumeration Date | 08/19/2020
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Last Update Date | 08/19/2020
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Provider Practice Location Address
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Address Line | 114 AIRPORT RD STE A
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City | PANAMA CITY
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State | FL
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Zip | 32405-4738
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Country | US
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Telephone | 850-832-3173
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 KINGSLEE DR
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City | PANAMA CITY
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State | FL
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Zip | 32409-3577
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Country | US
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Telephone | 850-832-3173
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRISTY FOGARTY
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Credential | LMHC
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Telephone | 850-463-0780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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