Provider Demographics
NPI:1225263783
Name:FANNING, JULIE (LCSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:FANNING
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 1:24 IONE DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2964
Mailing Address - Country:US
Mailing Address - Phone:847-220-1442
Mailing Address - Fax:
Practice Address - Street 1:164 DIVISION ST
Practice Address - Street 2:STE 505
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-5531
Practice Address - Country:US
Practice Address - Phone:847-220-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0121931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$01Medicaid
IL 5431Medicare UPIN