Provider Demographics
NPI:1316901812
Name:FAULKNER, DUSTIN MARK (PC)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:MARK
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 NILLES RD STE 5
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7205
Mailing Address - Country:US
Mailing Address - Phone:513-939-0300
Mailing Address - Fax:
Practice Address - Street 1:1251 NILLES RD STE 5
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7205
Practice Address - Country:US
Practice Address - Phone:513-939-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101Y00000X
OHC.0500461-CR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor