MEDICARE: MIRA ANN FANNING MA, LPCC, MFTC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPCC.0020398	CO

General Provider Information

NPI Number	:	1215636147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRA ANN FANNING MA, LPCC, MFTC

Provider Business Mailing Address
First Line	:	5687 S KING ST
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80123-2826
Country	:	US
Telephone Number	:	949-439-8836
Fax Number	:

Provider Business Practice Location Address
First Line	:	6087 S QUEBEC ST STE 102
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80111-4539
Country	:	US
Telephone Number	:	303-835-6992
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2023
Last Update Date	:	02/28/2023

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