Provider Demographics
NPI:1164078689
Name:FANCHER, MELODY CAROL
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:CAROL
Last Name:FANCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:SHRUM
Other - Last Name:FANCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:140 KAPTAIN DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-1199
Mailing Address - Country:US
Mailing Address - Phone:850-491-0979
Mailing Address - Fax:
Practice Address - Street 1:140 KAPTAIN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-1199
Practice Address - Country:US
Practice Address - Phone:850-491-0979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18527101YM0800X
FLMH19688101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682280OtherNATIONAL BOARD FOR CERTIFIED COUNSELORS, INC.