Provider Demographics
NPI:1437586120
Name:FAUSETT, CHARLY RENAE (MA, SLP-CF)
Entity Type:Individual
Prefix:MISS
First Name:CHARLY
Middle Name:RENAE
Last Name:FAUSETT
Suffix:
Gender:F
Credentials:MA, SLP-CF
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 383
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-0383
Mailing Address - Country:US
Mailing Address - Phone:417-354-0225
Mailing Address - Fax:417-354-0325
Practice Address - Street 1:2400 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-9620
Practice Address - Country:US
Practice Address - Phone:573-290-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013029960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist