Healthcare Provider Details

I. General information

NPI: 1013120054
Provider Name (Legal Business Name): MELISSA FANNIN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 LANSDOWNE DR
ASHLAND KY
41102
US

IV. Provider business mailing address

PO BOX 790
ASHLAND KY
41105-0790
US

V. Phone/Fax

Practice location:
  • Phone: 606-324-3005
  • Fax: 606-329-1530
Mailing address:
  • Phone: 606-329-8588
  • Fax: 606-329-8195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number103173
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: