Provider Demographics
NPI:1003935891
Name:FANCHER, PEGGY YOLANDA (LMSW, ACSW, BCETS)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:YOLANDA
Last Name:FANCHER
Suffix:
Gender:F
Credentials:LMSW, ACSW, BCETS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HHC 501ST SUSTAINMENT BRIGADE
Mailing Address - Street 2:UNIT 15476 BOX 198
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96260
Mailing Address - Country:KR
Mailing Address - Phone:858-605-1797
Mailing Address - Fax:
Practice Address - Street 1:12060 TIVOLI PARK ROW UNIT 6
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4372
Practice Address - Country:US
Practice Address - Phone:858-605-1797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0839441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical