Provider Demographics
NPI:1376186353
Name:FANTON, NATHAN (LCSW)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:FANTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CANAL STREET
Mailing Address - Street 2:4TH FLOOR, SUITE 458
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-520-4783
Mailing Address - Fax:
Practice Address - Street 1:90 CANAL STREET
Practice Address - Street 2:4TH FLOOR, SUITE 458
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-520-4783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116996104100000X
MA228613104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker