Healthcare Provider Details

I. General information

NPI: 1013397512
Provider Name (Legal Business Name): TAWNA FAYETTE BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 TERMINAL WAY SUITE 3
RENO NV
89502
US

IV. Provider business mailing address

2540 DICKERSON RD APT 12
RENO NV
89503-4900
US

V. Phone/Fax

Practice location:
  • Phone: 775-337-9359
  • Fax:
Mailing address:
  • Phone: 775-388-4826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: