Provider Demographics
NPI:1134284185
Name:FANDRICH, JOHN TERRY (LISW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:TERRY
Last Name:FANDRICH
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2329
Mailing Address - Country:US
Mailing Address - Phone:515-288-9181
Mailing Address - Fax:515-289-9109
Practice Address - Street 1:501 SW ANKENY RD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-9702
Practice Address - Country:US
Practice Address - Phone:515-289-2272
Practice Address - Fax:515-289-0126
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical