1003935891 NPI number — PEGGY YOLANDA FANCHER LMSW, ACSW, BCETS

Table of content: PEGGY YOLANDA FANCHER LMSW, ACSW, BCETS (NPI 1003935891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003935891 NPI number — PEGGY YOLANDA FANCHER LMSW, ACSW, BCETS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FANCHER
Provider First Name:
PEGGY
Provider Middle Name:
YOLANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW, ACSW, BCETS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003935891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HHC 501ST SUSTAINMENT BRIGADE
Provider Second Line Business Mailing Address:
UNIT 15476 BOX 198
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96260
Provider Business Mailing Address Country Code:
KR
Provider Business Mailing Address Telephone Number:
858-605-1797
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12060 TIVOLI PARK ROW UNIT 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92128-4372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-605-1797
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2007

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: 1041C0700X , with the licence number:  083944 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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