Provider Demographics
NPI:1144744053
Name:LOVE, FANYA NICHOLE
Entity Type:Individual
Prefix:
First Name:FANYA
Middle Name:NICHOLE
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SN BERNRDNO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-9630
Mailing Address - Country:US
Mailing Address - Phone:909-387-7332
Mailing Address - Fax:
Practice Address - Street 1:780 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-1003
Practice Address - Country:US
Practice Address - Phone:909-421-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW781881041C0700X
CA1210921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical