Healthcare Provider Details

I. General information

NPI: 1548808165
Provider Name (Legal Business Name): CAROL DANIELLE FAUVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 W PINE ST
HATTIESBURG MS
39401-4262
US

IV. Provider business mailing address

77 SAINT ANNES DR
HATTIESBURG MS
39401-8252
US

V. Phone/Fax

Practice location:
  • Phone: 601-447-4658
  • Fax:
Mailing address:
  • Phone: 601-408-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number19-108353
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: