Healthcare Provider Details

I. General information

NPI: 1649725680
Provider Name (Legal Business Name): CHARITY FANNIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PROFESSIONAL PARK DR
LOUISA KY
41230-9644
US

IV. Provider business mailing address

PO BOX 790
ASHLAND KY
41105-0790
US

V. Phone/Fax

Practice location:
  • Phone: 606-638-4332
  • Fax:
Mailing address:
  • Phone: 606-329-8588
  • Fax: 606-886-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number253260
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: