Healthcare Provider Details

I. General information

NPI: 1194916957
Provider Name (Legal Business Name): BARBARA ELLEN FANNIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date: 02/08/2021
Reactivation Date: 03/18/2021

III. Provider practice location address

4929 WILSHIRE BLVD SUITE NUMBER 510
LOS ANGELES CA
90010-3808
US

IV. Provider business mailing address

4929 WILSHIRE BLVD SUITE NUMBER 510
LOS ANGELES CA
90010-3808
US

V. Phone/Fax

Practice location:
  • Phone: 562-904-3999
  • Fax: 855-688-6746
Mailing address:
  • Phone: 562-904-3999
  • Fax: 855-688-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1050
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0172541
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1293
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: