Provider Demographics
NPI:1972654275
Name:FAWCETT, DAVID MICHAEL (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:FAWCETT
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUTIE 2
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1662
Mailing Address - Country:US
Mailing Address - Phone:954-776-3639
Mailing Address - Fax:954-776-3639
Practice Address - Street 1:2655 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1662
Practice Address - Country:US
Practice Address - Phone:954-776-3639
Practice Address - Fax:954-776-3639
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW60371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5207Medicare ID - Type UnspecifiedLCSW IND
FLE5207XMedicare PIN