Provider Demographics
NPI:1447345038
Name:FAUTZ, THERESA (LCSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FAUTZ
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 1:1448 GARDINER LANE
Mailing Address - Street 2:SUITE 202-203
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213
Mailing Address - Country:US
Mailing Address - Phone:502-456-9998
Mailing Address - Fax:502-456-9923
Practice Address - Street 1:1448 GARDINER LN
Practice Address - Street 2:SUITE202-203
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1978
Practice Address - Country:US
Practice Address - Phone:502-456-9998
Practice Address - Fax:502-456-9923
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1617101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY82001066Medicaid
KYCSW0281Medicare ID - Type Unspecified