Provider Demographics
NPI:1033667563
Name:JOHN FANNING, PH.D.
Entity Type:Organization
Organization Name:JOHN FANNING, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TRUMAN
Authorized Official - Last Name:FANNING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:504-421-0730
Mailing Address - Street 1:715 PECAN GROVE LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-1130
Mailing Address - Country:US
Mailing Address - Phone:504-421-0730
Mailing Address - Fax:888-959-6762
Practice Address - Street 1:4440 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5947
Practice Address - Country:US
Practice Address - Phone:504-421-0730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPSYCHOLOGY 468251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1552836Medicaid
LA1552836Medicaid
LAR15416Medicare UPIN