Provider Demographics
NPI:1699870295
Name:TOTA-FAUCETTE, MARY ELIZABETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:TOTA-FAUCETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 FRONTIS PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-277-1065
Mailing Address - Fax:
Practice Address - Street 1:125 BALDWIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3227
Practice Address - Country:US
Practice Address - Phone:704-316-1917
Practice Address - Fax:704-316-1924
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1886103T00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2815284AMedicare ID - Type Unspecified