Provider Demographics
NPI:1326474289
Name:ANGAW, FANTANESH
Entity Type:Individual
Prefix:
First Name:FANTANESH
Middle Name:
Last Name:ANGAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ELM DR APT 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-3617
Mailing Address - Country:US
Mailing Address - Phone:702-630-3458
Mailing Address - Fax:
Practice Address - Street 1:7368 N DECATUR BLVD
Practice Address - Street 2:UNIT 3
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-3070
Practice Address - Country:US
Practice Address - Phone:702-251-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NV8644-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV8644-COtherLCSW