Provider Demographics
NPI:1609120120
Name:FAWSON, ERIC C (MSW LCSW)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:C
Last Name:FAWSON
Suffix:
Gender:M
Credentials:MSW LCSW
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 1042
Mailing Address - Street 2:
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759-1042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 EAST BLUE MEADOW CIRCLE
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759-1042
Practice Address - Country:US
Practice Address - Phone:435-690-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59138793501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health