=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003935891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEGGY YOLANDA FANCHER LMSW, ACSW, BCETS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12060 TIVOLI PARK ROW UNIT 6
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-4372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-605-1797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HHC 501ST SUSTAINMENT BRIGADE UNIT 15476 BOX 198
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96260
-----------------------------------------------------
Country | KR
-----------------------------------------------------
Telephone | 858-605-1797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 083944
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------