Healthcare Provider Details

I. General information

NPI: 1699110742
Provider Name (Legal Business Name): DEBRA FANNING LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST FL 4
CANTON IL
61520-2608
US

IV. Provider business mailing address

PO BOX 604
BLOOMINGTON IL
61702-0604
US

V. Phone/Fax

Practice location:
  • Phone: 309-706-3190
  • Fax: 309-588-4115
Mailing address:
  • Phone: 309-706-3190
  • Fax: 309-588-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003689
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: