Provider Demographics
NPI:1407334634
Name:FANN, JULIE ELAINE (MED, LCMHC, NCC)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ELAINE
Last Name:FANN
Suffix:
Gender:F
Credentials:MED, LCMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2107 W KNOX ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4130
Mailing Address - Country:US
Mailing Address - Phone:919-670-2247
Mailing Address - Fax:919-462-0433
Practice Address - Street 1:113 EDINBURGH SOUTH DR STE 130
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6456
Practice Address - Country:US
Practice Address - Phone:919-670-2247
Practice Address - Fax:919-462-0433
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14088101YP2500X, 101YM0800X
NCA14088101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional