Provider Demographics
NPI:1578834990
Name:FAUSETT, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FAUSETT
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 1:2405 W I 44 SERVICE RD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-8771
Mailing Address - Country:US
Mailing Address - Phone:405-604-6801
Mailing Address - Fax:
Practice Address - Street 1:2405 W I 44 SERVICE RD
Practice Address - Street 2:SUITE 113
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8771
Practice Address - Country:US
Practice Address - Phone:405-604-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health