Provider Demographics
NPI:1457863276
Name:FAXON,, DOUGLAS JR (MS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:FAXON,
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7657 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2605
Mailing Address - Country:US
Mailing Address - Phone:267-978-1664
Mailing Address - Fax:
Practice Address - Street 1:7657 GILBERT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-2605
Practice Address - Country:US
Practice Address - Phone:267-978-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health