Provider Demographics
NPI:1790003358
Name:FATHEREE, DAVID M (LAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:M
Last Name:FATHEREE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:114 REPRESENTATIVE ROW
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3878
Mailing Address - Country:US
Mailing Address - Phone:337-412-6825
Mailing Address - Fax:337-504-4376
Practice Address - Street 1:114 REPRESENTATIVE ROW
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3878
Practice Address - Country:US
Practice Address - Phone:337-412-6825
Practice Address - Fax:337-504-4376
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA220101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)