MEDICARE: RICHARD FAUNTLEROY LICDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	976038	OH

General Provider Information

NPI Number	:	1255772620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD FAUNTLEROY LICDC

Provider Business Mailing Address
First Line	:	309 S 4TH ST
Second Line	:	STE 222
City	:	COLUMBUS
State	:	OH
Zip	:	43215-5428
Country	:	US
Telephone Number	:	614-221-9804
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 S 4TH ST
Second Line	:	STE 222
City	:	COLUMBUS
State	:	OH
Zip	:	43215-5428
Country	:	US
Telephone Number	:	614-221-9804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2013
Last Update Date	:	07/12/2013

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