1972739589 NPI number — SCHELLIE MICHELLE FANFAN LMHC, MS, EDS

Table of content: SCHELLIE MICHELLE FANFAN LMHC, MS, EDS (NPI 1972739589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972739589 NPI number — SCHELLIE MICHELLE FANFAN LMHC, MS, EDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FANFAN
Provider First Name:
SCHELLIE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC, MS, EDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FANFAN-SISSOKO
Provider Other First Name:
SCHELLIE
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMHC, MS, EDS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1972739589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 585509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32858-5509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-235-8151
Provider Business Mailing Address Fax Number:
407-452-3474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1617 E VINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34744-3740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-235-8151
Provider Business Practice Location Address Fax Number:
407-452-3474
Provider Enumeration Date:
06/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH8246 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 691610498 . This is a "MEDICAID WAIVER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 691610496 . This is a "MEDICAID WAIVER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 008772700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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