Basic Information
| Provider Information | |||||||||
| NPI: | 1497191050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAULK | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | LANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCMHC, LCAS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARNER | ||||||||
| OtherFirstName: | CAITLIN | ||||||||
| OtherMiddleName: | LANE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 615 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284126431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103430145 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 COASTAL HORIZONS DR | ||||||||
| Address2: | |||||||||
| City: | SHALLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284706094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107544515 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 11205 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | A11205 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 11205 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 21031 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.