Provider Demographics
NPI:1255570024
Name:FAISON, ETTA SERENA (LCSW)
Entity type:Individual
Prefix:MS
First Name:ETTA
Middle Name:SERENA
Last Name:FAISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 SERENITY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-8919
Mailing Address - Country:US
Mailing Address - Phone:910-224-8017
Mailing Address - Fax:
Practice Address - Street 1:210 S CLINTON AVE
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-4907
Practice Address - Country:US
Practice Address - Phone:910-337-3520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2010-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0062901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical