Basic Information
| Provider Information | |||||||||
| NPI: | 1730420530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAULK | ||||||||
| FirstName: | SANDY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIMBALL | ||||||||
| OtherFirstName: | SANDY | ||||||||
| OtherMiddleName: | FAULK | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4105 KIRKMAN ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706070603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374758022 | ||||||||
| FaxNumber: | 3374758054 | ||||||||
| Practice Location | |||||||||
| Address1: | 4105 KIRKMAN ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706074603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374758022 | ||||||||
| FaxNumber: | 3374758054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2013 | ||||||||
| LastUpdateDate: | 03/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.