Provider Demographics
NPI:1235530205
Name:FANTORE, DANIEL
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:FANTORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32050 DOHANY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-1820
Mailing Address - Country:US
Mailing Address - Phone:313-683-0637
Mailing Address - Fax:
Practice Address - Street 1:1333 BREWERY PARK BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4544
Practice Address - Country:US
Practice Address - Phone:313-656-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086603104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker