Provider Demographics
NPI:1073363289
Name:EDOUARD, FABIENNE
Entity Type:Individual
Prefix:
First Name:FABIENNE
Middle Name:
Last Name:EDOUARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 SATELLITE BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-6286
Mailing Address - Country:US
Mailing Address - Phone:404-295-7941
Mailing Address - Fax:
Practice Address - Street 1:1845 SATELLITE BLVD STE 800
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-6286
Practice Address - Country:US
Practice Address - Phone:404-295-7941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician