Provider Demographics
NPI:1124491105
Name:PHILIP J FAUERBACH, LMHC
Entity type:Organization
Organization Name:PHILIP J FAUERBACH, LMHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAUERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:8813-651-1221
Mailing Address - Street 1:3812 HANOVER HILL DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7161
Mailing Address - Country:US
Mailing Address - Phone:813-681-7662
Mailing Address - Fax:813-657-0850
Practice Address - Street 1:915 S PARSONS AVE # C
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6008
Practice Address - Country:US
Practice Address - Phone:813-651-1221
Practice Address - Fax:813-657-0850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL761087400Medicaid
FL761087400Medicaid