MEDICARE: TAKEYA FAISON

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

General Provider Information

NPI Number	:	1922665777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAKEYA FAISON

Provider Business Mailing Address
First Line	:	172 NEWBURY ST
Second Line	:
City	:	PEABODY
State	:	MA
Zip	:	01960-2405
Country	:	US
Telephone Number	:	978-535-9190
Fax Number	:

Provider Business Practice Location Address
First Line	:	172 NEWBURY ST
Second Line	:
City	:	PEABODY
State	:	MA
Zip	:	01960-2405
Country	:	US
Telephone Number	:	978-535-9190
Fax Number	:

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

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	05/28/2019

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