Basic Information
| Provider Information | |||||||||
| NPI: | 1720605959 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYDON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2603 W BAINBRIDGE CIR | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775845908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143741543 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5304 ALMEDA RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770047440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143741543 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2020 | ||||||||
| LastUpdateDate: | 07/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | HATTER | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3143741543 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | 07/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 77890 | 01 | TX | TEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS | OTHER |