Provider Demographics
NPI:1740355817
Name:FAUTH, P RICHARD (PHD)
Entity type:Individual
Prefix:MR
First Name:P
Middle Name:RICHARD
Last Name:FAUTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 WINTON ROAD SOUTH
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:585-256-3050
Mailing Address - Fax:585-267-1182
Practice Address - Street 1:920 WINTON ROAD SOUTH
Practice Address - Street 2:SUITE A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618
Practice Address - Country:US
Practice Address - Phone:585-256-3050
Practice Address - Fax:585-267-1182
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0093281103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01109737Medicaid
4580504OtherAETNA