MEDICARE: CELENA D FANNIN LCSW

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	101YM0800X	Mental Health Counselor	61959	TX
2	171M00000X	Case Manager/Care Coordinator	61959	TX
3	1041C0700X	Clinical Social Worker	61959	TX

General Provider Information

NPI Number	:	1407640816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CELENA D FANNIN LCSW

Provider Business Mailing Address
First Line	:	3612 WREN AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2131
Country	:	US
Telephone Number	:	817-718-8366
Fax Number	:

Provider Business Practice Location Address
First Line	:	3612 WREN AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2131
Country	:	US
Telephone Number	:	817-718-8366
Fax Number	:

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

Provider Enumeration Date	:	04/09/2025
Last Update Date	:	07/25/2025

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