MEDICARE: EMILY FANKHAUSER LAC

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	LAC-22426	AZ

General Provider Information

NPI Number	:	1891579165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY FANKHAUSER LAC

Provider Business Mailing Address
First Line	:	3707 E SOUTHERN AVE STE 2028
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-6214
Country	:	US
Telephone Number	:	602-693-3915
Fax Number	:

Provider Business Practice Location Address
First Line	:	3707 E SOUTHERN AVE STE 2028
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-6214
Country	:	US
Telephone Number	:	602-693-3915
Fax Number	:

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

Provider Enumeration Date	:	08/18/2023
Last Update Date	:	08/18/2023

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