Healthcare Provider Details

I. General information

NPI: 1609231711
Provider Name (Legal Business Name): NANCY FADER MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 03/14/2020
Certification Date: 03/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 THORN ST
SAN DIEGO CA
92103-5629
US

IV. Provider business mailing address

1085 12TH ST UNIT C
IMPERIAL BEACH CA
91932-2948
US

V. Phone/Fax

Practice location:
  • Phone: 619-431-0046
  • Fax:
Mailing address:
  • Phone: 619-823-9782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number95040
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number95040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: