Provider Demographics
NPI:1578072336
Name:FAUQUET, SIMONE GENEVIEVE (PSS STUDENT)
Entity Type:Individual
Prefix:MISS
First Name:SIMONE
Middle Name:GENEVIEVE
Last Name:FAUQUET
Suffix:
Gender:F
Credentials:PSS STUDENT
Other - Prefix:MS
Other - First Name:SIMONE
Other - Middle Name:G
Other - Last Name:FAUQUET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSS STUDENT
Mailing Address - Street 1:621 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3241
Mailing Address - Country:US
Mailing Address - Phone:805-202-3440
Mailing Address - Fax:
Practice Address - Street 1:621 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3241
Practice Address - Country:US
Practice Address - Phone:805-202-3440
Practice Address - Fax:805-202-3441
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABL17-000035390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831541986OtherADDICTION MEDICINE