MEDICARE: FAD COUNSELING SERVICES LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1164856829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAD COUNSELING SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 72
Second Line	:
City	:	WASHINGTON
State	:	GA
Zip	:	30673-0072
Country	:	US
Telephone Number	:	706-678-5667
Fax Number	:	888-495-7489

Provider Business Practice Location Address
First Line	:	311 SPRING ST
Second Line	:
City	:	WASHINGTON
State	:	GA
Zip	:	30673-1717
Country	:	US
Telephone Number	:	706-678-5667
Fax Number	:	888-495-7489

Authorized Official
Title or Position	:	OWNER
Name	:	MR. FULANI AREKA DOUGHTY
Credential	:	LPC, NCC, CRC, CAADC
Telephone Number	:	706-678-5667

Provider Enumeration Date	:	08/29/2013
Last Update Date	:	08/29/2013

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