Healthcare Provider Details

I. General information

NPI: 1831523711
Provider Name (Legal Business Name): DORENE FANNING LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 JOHN JONES RD
DAVIS CA
95616-9701
US

IV. Provider business mailing address

PO BOX 1260
DAVIS CA
95617-1260
US

V. Phone/Fax

Practice location:
  • Phone: 530-753-3498
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS29760
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: