Provider Demographics
NPI:1396075602
Name:FORTIN, PEGGY KAY (LPC)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:KAY
Last Name:FORTIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48621-8703
Mailing Address - Country:US
Mailing Address - Phone:989-848-5644
Mailing Address - Fax:989-848-7411
Practice Address - Street 1:1392 MAPLE DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:MI
Practice Address - Zip Code:48621-8703
Practice Address - Country:US
Practice Address - Phone:989-848-5644
Practice Address - Fax:989-848-7411
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional