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General NPI Number Information
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NPI Number | 1710192935
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Entity Type | Individual
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Provider Name | GORDON LANE FAISON NA LCMHC
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Gender | Male
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 54 HARRIS PLACE
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City | BRATTLEBORO
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State | VT
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Zip | 05301
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Country | US
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Telephone | 802-380-0695
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6262
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City | BRATTLEBORO
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State | VT
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Zip | 05302
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Country | US
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Telephone | 802-380-0695
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number | 068-0000321
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License Number State | VT
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