Healthcare Provider Details

I. General information

NPI: 1043127350
Provider Name (Legal Business Name): LILLY ETTA FAUST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LILLY ETTA SACON

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 W GARRIOTT RD STE F
ENID OK
73703-5653
US

IV. Provider business mailing address

2057 LANTERN LN
ENID OK
73703-1636
US

V. Phone/Fax

Practice location:
  • Phone: 580-242-4673
  • Fax: 580-242-4679
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: