Provider Demographics
NPI:1992677991
Name:FOGARTY, PEYTON
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 PADDINGTON CT UNIT 5
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-9523
Mailing Address - Country:US
Mailing Address - Phone:843-455-8765
Mailing Address - Fax:
Practice Address - Street 1:2952 LITTLE BETHEL RD
Practice Address - Street 2:
Practice Address - City:GREEN SEA
Practice Address - State:SC
Practice Address - Zip Code:29545-3729
Practice Address - Country:US
Practice Address - Phone:843-733-2184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty