=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285092932
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER RENEE FAULKNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2016
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 BREWSTER BLVD
-----------------------------------------------------
City | CAMP LEJEUNE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28547-2575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-450-4278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7794 GRANT AVENUE RD
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13021-8207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-406-5149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C011912
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 105420
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW.09925794
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------