Provider Demographics
NPI:1417459132
Name:FANNIN, STEPHEN DALE (EDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DALE
Last Name:FANNIN
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 COLONY RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-6342
Mailing Address - Country:US
Mailing Address - Phone:757-877-3132
Mailing Address - Fax:
Practice Address - Street 1:2801 TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-4630
Practice Address - Country:US
Practice Address - Phone:757-393-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool