Healthcare Provider Details

I. General information

NPI: 1891609400
Provider Name (Legal Business Name): SAVANNAH CONNELLY-FANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 MARKET ST STE 306
HAVRE DE GRACE MD
21078-3280
US

IV. Provider business mailing address

55 OLD SOUND RD
JOPPA MD
21085-4540
US

V. Phone/Fax

Practice location:
  • Phone: 443-528-6379
  • Fax:
Mailing address:
  • Phone: 443-528-6379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP17380
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: