Provider Demographics
NPI:1578633343
Name:MCGOURTY, PETER GERALD (LPC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:GERALD
Last Name:MCGOURTY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 ATHENA PL
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7797
Mailing Address - Country:US
Mailing Address - Phone:803-396-8945
Mailing Address - Fax:
Practice Address - Street 1:6025 BLAKENEY PARK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-5703
Practice Address - Country:US
Practice Address - Phone:704-831-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3436101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health