Healthcare Provider Details

I. General information

NPI: 1154509594
Provider Name (Legal Business Name): FANNIE LOOKINGGLASS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 160 & NAVAJO ROUTE 25 - RED MESA
TEECNOSPOS AZ
86514
US

IV. Provider business mailing address

HCR 6100, BOX 30
TEECNOSPOS AZ
86514
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5137
  • Fax: 928-656-5132
Mailing address:
  • Phone: 928-656-5137
  • Fax: 928-656-5132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-0824
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: