Provider Demographics
NPI:1043056047
Name:FANCY MESSY, LLC
Entity type:Organization
Organization Name:FANCY MESSY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:585-955-3655
Mailing Address - Street 1:725 SOUTHWICK AVE
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-4278
Mailing Address - Country:US
Mailing Address - Phone:585-955-3655
Mailing Address - Fax:
Practice Address - Street 1:4812 TECHNOLOGY DR BLDG 1
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3912
Practice Address - Country:US
Practice Address - Phone:762-218-3794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health