Provider Demographics
NPI:1003962325
Name:TAM, FANNIE L (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:FANNIE
Middle Name:L
Last Name:TAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 FRENCHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:E GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1816
Mailing Address - Country:US
Mailing Address - Phone:401-884-0758
Mailing Address - Fax:
Practice Address - Street 1:235 FRENCHTOWN RD
Practice Address - Street 2:
Practice Address - City:E GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1816
Practice Address - Country:US
Practice Address - Phone:401-884-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI 00397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health