Provider Demographics
NPI:1740319060
Name:FORTNER, KATHY LEE (EDS, LPC)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:LEE
Last Name:FORTNER
Suffix:
Gender:F
Credentials:EDS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7139
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-0007
Mailing Address - Country:US
Mailing Address - Phone:843-240-9446
Mailing Address - Fax:866-647-6536
Practice Address - Street 1:1107 48TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5443
Practice Address - Country:US
Practice Address - Phone:843-240-9446
Practice Address - Fax:866-647-6536
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4632101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health