Provider Demographics
NPI:1265043376
Name:FANNING, MATT (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:FANNING
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 W PINE BLVD APT 103
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3237
Mailing Address - Country:US
Mailing Address - Phone:314-372-9738
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKINGS DRIVE
Practice Address - Street 2:SEIGLE HALL, STE 435
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-4889
Practice Address - Country:US
Practice Address - Phone:314-935-8457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200228371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical