Healthcare Provider Details

I. General information

NPI: 1619385200
Provider Name (Legal Business Name): ANASTASIA FANASELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6707 WHITESTONE RD STE 106
GWYNN OAK MD
21207-4140
US

IV. Provider business mailing address

6707 WHITESTONE RD STE 106
GWYNN OAK MD
21207-4140
US

V. Phone/Fax

Practice location:
  • Phone: 410-265-8737
  • Fax:
Mailing address:
  • Phone: 410-265-8737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP5389
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: