Provider Demographics
NPI:1447326475
Name:FAY, RICHARD A (LCSW)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:FAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8871
Mailing Address - Country:US
Mailing Address - Phone:386-986-8662
Mailing Address - Fax:
Practice Address - Street 1:59 BAYSIDE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8871
Practice Address - Country:US
Practice Address - Phone:386-986-8662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
FLSW84891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7660880 00Medicaid
FL8117225 00Medicaid