Provider Demographics
NPI:1376916411
Name:FAULKNER, SAMUEL (PHD, CSW)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:PHD, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-784-4161
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:321 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1671
Practice Address - Country:US
Practice Address - Phone:606-784-4161
Practice Address - Fax:606-329-8195
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7269251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health