Healthcare Provider Details

I. General information

NPI: 1083206882
Provider Name (Legal Business Name): MR. GREGORY MICHAEL FAUST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 FAIR AVE
SANTA CRUZ CA
95060-5828
US

IV. Provider business mailing address

2020 17TH AVE # A
SANTA CRUZ CA
95062-1808
US

V. Phone/Fax

Practice location:
  • Phone: 831-427-1007
  • Fax: 831-454-0545
Mailing address:
  • Phone: 831-359-1091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: