Provider Demographics
NPI:1336323278
Name:FANARA, MICHAEL (CMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:FANARA
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 CITTA CT
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8362
Mailing Address - Country:US
Mailing Address - Phone:732-505-6759
Mailing Address - Fax:
Practice Address - Street 1:1133 CITTA CT
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8362
Practice Address - Country:US
Practice Address - Phone:732-505-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26BT00014700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist