MEDICARE: MS. ELISA ANGELYN FANLO MS, MA, LCMHC, LCAS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	2423	NC

General Provider Information

NPI Number	:	1396051645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELISA ANGELYN FANLO MS, MA, LCMHC, LCAS

Provider Business Mailing Address
First Line	:	364 RALEIGH ST
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9047
Country	:	US
Telephone Number	:	919-647-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	364 RALEIGH ST
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9047
Country	:	US
Telephone Number	:	919-647-4600
Fax Number	:

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

Provider Enumeration Date	:	08/25/2010
Last Update Date	:	09/23/2025

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