MEDICARE: MR. HENRY FUQUA CADC

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	119050	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	119050	OTHER	KY	CERTIFIED ALCOHOL & DRUG CONSOLER LICENSE #

General Provider Information

NPI Number	:	1285445841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY FUQUA CADC

Provider Business Mailing Address
First Line	:	1675 STORY AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-1739
Country	:	US
Telephone Number	:	502-749-6344
Fax Number	:	502-749-6344

Provider Business Practice Location Address
First Line	:	1675 STORY AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-1739
Country	:	US
Telephone Number	:	502-749-6344
Fax Number	:	502-749-6344

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

Provider Enumeration Date	:	01/14/2025
Last Update Date	:	01/14/2025

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