Healthcare Provider Details

I. General information

NPI: 1043286636
Provider Name (Legal Business Name): MARY ADRIENNE FANSLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ADRIENNE FANSLER LCSW

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1237 N RIVERSIDE AVE SUITE 229
MEDFORD OR
97501
US

IV. Provider business mailing address

PO BOX 1787
MEDFORD OR
97501-0261
US

V. Phone/Fax

Practice location:
  • Phone: 541-500-8655
  • Fax:
Mailing address:
  • Phone: 541-500-8655
  • Fax: 800-433-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL2117
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: