=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083471858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLEY FAULKNER LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2024
-----------------------------------------------------
Last Update Date | 03/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 CLAREMONT LN STE 103
-----------------------------------------------------
City | CROZET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22932-3455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-466-1588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2548 TAYLORS GAP RD
-----------------------------------------------------
City | NORTH GARDEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22959-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-460-9958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 701012879
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------