Basic Information
| Provider Information | |||||||||
| NPI: | 1073765004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FESUK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | BORIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 S 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765014726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545264146 | ||||||||
| FaxNumber: | 2545269351 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E AVENUE A | ||||||||
| Address2: | |||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765414763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545264146 | ||||||||
| FaxNumber: | 2545269351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2008 | ||||||||
| LastUpdateDate: | 10/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 201272 | TX | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.