Provider Demographics
NPI:1083162275
Name:FANNAN, EMILY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:
Last Name:FANNAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6349 RANCHO MISSION RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2007
Mailing Address - Country:US
Mailing Address - Phone:707-217-8908
Mailing Address - Fax:
Practice Address - Street 1:3665 KEARNY VILLA RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1954
Practice Address - Country:US
Practice Address - Phone:858-966-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA885661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical