Alyse Fandrich
Individual provider Active NPI Professional Counselor · Baxley, GA
NPI 1508418203 · NPPES record last updated Jul 12, 2019
Key facts
- NPI
- 1508418203
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Professional Counselor 101YP2500X
- License
- LPC010854 (GA)
- Practice address
- 755 S Main St
Baxley, GA 31513-0130 - Phone
- (912) 367-4614
- Fax
- (912) 367-9048
- NPI assigned
- Jul 12, 2019
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Mental Health Counselor
- Education
- Other, 2014
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
5 W Altman St
Stateboro, GA 30458-5212
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20260624000843 | GA | Practitioner - Mental Health Counselor | 7517430341 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LPC010854 | GA | MD | Professional Counselor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pineland Area Community Services Board | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | LPC010854 | GA | Yes |
Addresses
Primary practice location
755 S Main St
Baxley, GA 31513-0130
Mailing address
755 S Main St
Baxley, GA 31513-0130
Phone (912) 367-4614
Other providers in Baxley, GA
- East Georgia Healthcare Center Inc
- Melina Edmund
- Barbara Nicole Ellis
- Excelcare Ambulance Service, Inc
- Family Medicine of Baxley Inc.
- Roxany Fernandez
- Orlando V Fernando
- Janet Leona Flounory
- Tonya Fowler Fordham
- Santina Fryer
All providers in Baxley, GA · Professional Counselor in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 12, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.