Healthcare Provider Details

I. General information

NPI: 1952036733
Provider Name (Legal Business Name): MR. GEOFFREY S FANNIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 GRANT ST
PORTSMOUTH OH
45662-3663
US

IV. Provider business mailing address

1616 GRANT ST
PORTSMOUTH OH
45662-3663
US

V. Phone/Fax

Practice location:
  • Phone: 740-901-0416
  • Fax:
Mailing address:
  • Phone: 937-260-5652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.1800093
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: