Provider Demographics
NPI:1255772620
Name:FAUNTLEROY, RICHARD (LICDC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:FAUNTLEROY
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S 4TH ST
Mailing Address - Street 2:STE 222
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5428
Mailing Address - Country:US
Mailing Address - Phone:614-221-9804
Mailing Address - Fax:
Practice Address - Street 1:309 S 4TH ST
Practice Address - Street 2:STE 222
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5428
Practice Address - Country:US
Practice Address - Phone:614-221-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH976038101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)