Provider Demographics
NPI:1033949342
Name:FAUST, EDRA LATRELLE (APC)
Entity type:Individual
Prefix:
First Name:EDRA
Middle Name:LATRELLE
Last Name:FAUST
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 STRICKLAND ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1261
Mailing Address - Country:US
Mailing Address - Phone:678-838-8333
Mailing Address - Fax:
Practice Address - Street 1:6311 STRICKLAND ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1261
Practice Address - Country:US
Practice Address - Phone:678-838-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC008879101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty