Provider Demographics
NPI:1164743613
Name:FOFANOVA, LAUREN LOYAL (LCSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:LOYAL
Last Name:FOFANOVA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:LOYAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3526 CEDAR HILL CT
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2683
Mailing Address - Country:US
Mailing Address - Phone:713-203-6947
Mailing Address - Fax:
Practice Address - Street 1:627 W 19TH ST STE 201
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-3658
Practice Address - Country:US
Practice Address - Phone:713-203-6947
Practice Address - Fax:866-234-3779
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX510071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical