MEDICARE: FAYDON LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	77890	OTHER	TX	TEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS

General Provider Information

NPI Number	:	1720605959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYDON LLC

Provider Business Mailing Address
First Line	:	2603 W BAINBRIDGE CIR
Second Line	:
City	:	PEARLAND
State	:	TX
Zip	:	77584-5908
Country	:	US
Telephone Number	:	314-374-1543
Fax Number	:

Provider Business Practice Location Address
First Line	:	5304 ALMEDA RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-7440
Country	:	US
Telephone Number	:	314-374-1543
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DANA HATTER
Credential	:	LPC
Telephone Number	:	314-374-1543

Provider Enumeration Date	:	07/03/2020
Last Update Date	:	07/03/2020

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Directions to “FAYDON LLC ” Practice Location

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