Provider Demographics
NPI:1427540509
Name:FANDAL, FAWN (MA, PLPC)
Entity Type:Individual
Prefix:MRS
First Name:FAWN
Middle Name:
Last Name:FANDAL
Suffix:
Gender:F
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14400 LAKE TAHOE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-6951
Mailing Address - Country:US
Mailing Address - Phone:985-774-4643
Mailing Address - Fax:985-288-5405
Practice Address - Street 1:1310 BROWNSWITCH RD STE D
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-1611
Practice Address - Country:US
Practice Address - Phone:985-774-4643
Practice Address - Fax:985-288-5405
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7417101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor