Provider Demographics
NPI:1912125527
Name:FAUERBACH, PHILIP JOHN (LMHC)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JOHN
Last Name:FAUERBACH
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3812 HANOVER HILL DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7161
Mailing Address - Country:US
Mailing Address - Phone:813-651-1221
Mailing Address - Fax:813-657-0850
Practice Address - Street 1:915 S PARSONS AVE
Practice Address - Street 2:# C
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6008
Practice Address - Country:US
Practice Address - Phone:813-651-1221
Practice Address - Fax:813-657-0850
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL761087400Medicaid
FLZ5785Medicare UPIN