Healthcare Provider Details

I. General information

NPI: 1457863276
Provider Name (Legal Business Name): DOUGLAS FAXON, JR. MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7657 GILBERT ST
PHILADELPHIA PA
19150-2605
US

IV. Provider business mailing address

7657 GILBERT ST
PHILADELPHIA PA
19150-2605
US

V. Phone/Fax

Practice location:
  • Phone: 267-978-1664
  • Fax:
Mailing address:
  • Phone: 267-978-1664
  • 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: