Provider Demographics
NPI:1407025729
Name:FONGHEISER, ANNIE (MA, MS, MAC, LCAS)
Entity Type:Individual
Prefix:MS
First Name:ANNIE
Middle Name:
Last Name:FONGHEISER
Suffix:
Gender:F
Credentials:MA, MS, MAC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 ARROWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-1503
Mailing Address - Country:US
Mailing Address - Phone:803-730-2282
Mailing Address - Fax:
Practice Address - Street 1:5700 EXECUTIVE CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8833
Practice Address - Country:US
Practice Address - Phone:803-730-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC945101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC148UGOtherBCBS
NC6112011Medicaid
9407152OtherAETNA