Provider Demographics
NPI:1063011393
Name:FAULKNER, LUCY KAITLYN (MA)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:KAITLYN
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2342
Mailing Address - Country:US
Mailing Address - Phone:203-430-3577
Mailing Address - Fax:
Practice Address - Street 1:17A WOODLAND RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2342
Practice Address - Country:US
Practice Address - Phone:203-779-5490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4269101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional