Provider Demographics
NPI:1013286129
Name:FAWSON, AMMON KC (LMFT)
Entity Type:Individual
Prefix:
First Name:AMMON
Middle Name:KC
Last Name:FAWSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6032
Mailing Address - Country:US
Mailing Address - Phone:801-648-9742
Mailing Address - Fax:
Practice Address - Street 1:1045 8TH AVE NW
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:MN
Practice Address - Zip Code:55920-1590
Practice Address - Country:US
Practice Address - Phone:801-603-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8375045-3902106H00000X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No253J00000XAgenciesFoster Care Agency