Provider Demographics
NPI:1972136703
Name:FAUGHT, RYAN M (LMBT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:FAUGHT
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S MAIN ST STE 113
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-3549
Mailing Address - Country:US
Mailing Address - Phone:980-277-0663
Mailing Address - Fax:
Practice Address - Street 1:500 S MAIN ST STE 113
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-3549
Practice Address - Country:US
Practice Address - Phone:802-770-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0023734225700000X
OH33.013833225700000X
NC20514225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist