=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740477058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANDLER REED FAUSNAUGH LMHC, CAP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 N SUMMERLIN AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32801-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-277-2443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 SUMMERLAND AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-1445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-277-2443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH8241
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------