Provider Demographics
NPI:1245613108
Name:FANGMAN, MARVIN (MA, IAADC)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
Last Name:FANGMAN
Suffix:
Gender:M
Credentials:MA, IAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15806 WILDWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325
Mailing Address - Country:US
Mailing Address - Phone:515-371-1166
Mailing Address - Fax:
Practice Address - Street 1:501 NORTH SHERMAN
Practice Address - Street 2:
Practice Address - City:PRAIRIE CITY
Practice Address - State:IA
Practice Address - Zip Code:50228
Practice Address - Country:US
Practice Address - Phone:515-994-3562
Practice Address - Fax:515-994-3564
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA10167101YA0400X
VI0-24094-1B104100000X
IA015461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical