MEDICARE: MRS. ALZIRENE CAMPOS FAUBION M.A.

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	171M00000X	Case Manager/Care Coordinator
2	101Y00000X	Counselor	LPC006470	GA
3	101YP2500X	Professional Counselor	LPC006470-APT-T-1972	GA

General Provider Information

NPI Number	:	1851419188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALZIRENE CAMPOS FAUBION M.A.

Provider Business Mailing Address
First Line	:	105 GOVERNORS SQ
Second Line	:	SUITE 602
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-4866
Country	:	US
Telephone Number	:	678-925-3306
Fax Number	:	678-985-4855

Provider Business Practice Location Address
First Line	:	105 GOVERNORS SQ
Second Line	:	SUITE 602
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-4866
Country	:	US
Telephone Number	:	678-925-3306
Fax Number	:	678-985-4855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	11/30/2016

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