Healthcare Provider Details

I. General information

NPI: 1043056047
Provider Name (Legal Business Name): FANCY MESSY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 TECHNOLOGY DR BLDG 1
AUGUSTA GA
30907-3912
US

IV. Provider business mailing address

725 SOUTHWICK AVE
GROVETOWN GA
30813-4278
US

V. Phone/Fax

Practice location:
  • Phone: 762-218-3794
  • Fax:
Mailing address:
  • Phone: 585-955-3655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LAUREN PETRO
Title or Position: OWNER
Credential: LPC, NCC
Phone: 585-955-3655