MEDICARE: FOX EVALUATION AND CONSULTING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3452	NC

General Provider Information

NPI Number	:	1053743179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOX EVALUATION AND CONSULTING

Provider Business Mailing Address
First Line	:	505 WANDERVIEW LN
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-6258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	505 WANDERVIEW LN
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-6258
Country	:	US
Telephone Number	:	919-348-1488
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KOLLEEN FOX
Credential	:	PHD
Telephone Number	:	919-348-1488

Provider Enumeration Date	:	07/31/2013
Last Update Date	:	08/30/2013

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