Healthcare Provider Details

I. General information

NPI: 1861849234
Provider Name (Legal Business Name): PATRICK FANNON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W 57TH ST FL 2
NEW YORK NY
10019-1775
US

IV. Provider business mailing address

475 W 57TH ST FL 2
NEW YORK NY
10019-1775
US

V. Phone/Fax

Practice location:
  • Phone: 818-445-3660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0881551
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: