Healthcare Provider Details

I. General information

NPI: 1740378751
Provider Name (Legal Business Name): CHARMAINE ANN FANARA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 11/08/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 ALYS DR E
DEPEW NY
14043-1402
US

IV. Provider business mailing address

59 ALYS DR E
DEPEW NY
14043-1402
US

V. Phone/Fax

Practice location:
  • Phone: 716-783-0407
  • Fax: 716-393-3430
Mailing address:
  • Phone: 716-391-7356
  • Fax: 716-393-3430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071265-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: