Healthcare Provider Details

I. General information

NPI: 1033667563
Provider Name (Legal Business Name): JOHN FANNING, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 CANAL ST
NEW ORLEANS LA
70119-5947
US

IV. Provider business mailing address

715 PECAN GROVE LN
JEFFERSON LA
70121-1130
US

V. Phone/Fax

Practice location:
  • Phone: 504-421-0730
  • Fax:
Mailing address:
  • Phone: 504-421-0730
  • Fax: 888-959-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPSYCHOLOGY 468
License Number StateLA

VIII. Authorized Official

Name: DR. JOHN TRUMAN FANNING
Title or Position: CLINICAL NEUROPSYCHOLOGIST
Credential: PHD
Phone: 504-421-0730