Provider Demographics
NPI:1679023618
Name:FUQUAY, CARLA (IMHC)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:FUQUAY
Suffix:
Gender:F
Credentials:IMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-3919
Mailing Address - Country:US
Mailing Address - Phone:561-371-5171
Mailing Address - Fax:
Practice Address - Street 1:1663 DUNLAP DR
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4400
Practice Address - Country:US
Practice Address - Phone:561-371-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH120007101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health