Provider Demographics
NPI:1851419188
Name:FAUBION, ALZIRENE CAMPOS (MA)
Entity Type:Individual
Prefix:MRS
First Name:ALZIRENE
Middle Name:CAMPOS
Last Name:FAUBION
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 GOVERNORS SQ
Mailing Address - Street 2:SUITE 602
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4866
Mailing Address - Country:US
Mailing Address - Phone:678-925-3306
Mailing Address - Fax:678-985-4855
Practice Address - Street 1:105 GOVERNORS SQ
Practice Address - Street 2:SUITE 602
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4866
Practice Address - Country:US
Practice Address - Phone:678-925-3306
Practice Address - Fax:678-985-4855
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
GALPC006470101Y00000X
GALPC006470-APT-T-1972101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA463040961AMedicaid