MEDICARE: MRS. DANIELLE ELIZABETH FANSLOW BSW, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	306546	MN

General Provider Information

NPI Number	:	1093426793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANIELLE ELIZABETH FANSLOW BSW, LADC

Provider Business Mailing Address
First Line	:	343 WOODLAKE DR SE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55904-6242
Country	:	US
Telephone Number	:	507-289-2089
Fax Number	:	507-535-5798

Provider Business Practice Location Address
First Line	:	29 7TH ST NE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55906-3644
Country	:	US
Telephone Number	:	507-289-2089
Fax Number	:	507-535-5798

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2022
Last Update Date	:	12/13/2022

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