Provider Demographics
NPI:1659453652
Name:FAUNTLEROY, NANCY (LCSWC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:FAUNTLEROY
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8737 BROOKS DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-7411
Mailing Address - Country:US
Mailing Address - Phone:410-770-3060
Mailing Address - Fax:410-770-5860
Practice Address - Street 1:8737 BROOKS DR
Practice Address - Street 2:SUITE 108
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7411
Practice Address - Country:US
Practice Address - Phone:410-770-3060
Practice Address - Fax:410-770-5860
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD081241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKK81LB39Medicare ID - Type Unspecified