Healthcare Provider Details

I. General information

NPI: 1639082837
Provider Name (Legal Business Name): NICHOLAS JOHN FASONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W WADE HAMPTON BLVD STE 3B
GREER SC
29650-1296
US

IV. Provider business mailing address

2636 ROSEGLEN LN
INDIAN LAND SC
29707-7956
US

V. Phone/Fax

Practice location:
  • Phone: 864-334-5019
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.12561
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: