Provider Demographics
NPI:1609654417
Name:FAULKNER, MIA (LPCA)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4248
Mailing Address - Country:US
Mailing Address - Phone:270-556-2370
Mailing Address - Fax:
Practice Address - Street 1:3565 LONE OAK RD STE 2
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-5717
Practice Address - Country:US
Practice Address - Phone:270-554-3714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY287245101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health