Provider Demographics
NPI:1952453573
Name:FAWSON, NATHAN A (LMLP)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:FAWSON
Suffix:
Gender:M
Credentials:LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 N WALNUT RD E
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749
Mailing Address - Country:US
Mailing Address - Phone:620-365-6891
Mailing Address - Fax:
Practice Address - Street 1:304 N JEFFERSON
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749
Practice Address - Country:US
Practice Address - Phone:620-365-5717
Practice Address - Fax:620-365-8642
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMLP990103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent