Provider Demographics
NPI:1265044499
Name:FOGARTY WELLNESS LLC
Entity Type:Organization
Organization Name:FOGARTY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:850-463-0780
Mailing Address - Street 1:1801 KINGSLEE DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32409-3577
Mailing Address - Country:US
Mailing Address - Phone:850-832-3173
Mailing Address - Fax:
Practice Address - Street 1:114 AIRPORT RD STE A
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4738
Practice Address - Country:US
Practice Address - Phone:850-832-3173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty