=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568204063
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDY FANCHER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2024
-----------------------------------------------------
Last Update Date | 06/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 S RIDGEWOOD AVE STE 204C-205
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-747-6541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1562 ALDRIDGE LN
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-0845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-785-9972
-----------------------------------------------------
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 | ISW20463
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------