Provider Demographics
NPI:1043286636
Name:FANSLER, MARY ADRIENNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ADRIENNE
Last Name:FANSLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ADRIENNE
Other - Last Name:FANSLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1237 N RIVERSIDE AVE
Mailing Address - Street 2:SUITE 229
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501
Mailing Address - Country:US
Mailing Address - Phone:541-779-8850
Mailing Address - Fax:541-858-5441
Practice Address - Street 1:1237 N RIVERSIDE AVE
Practice Address - Street 2:SUITE 229
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-779-8850
Practice Address - Fax:541-858-5441
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL21171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR104832Medicare UPIN