Provider Demographics
NPI:1437441466
Name:FANT, MAIMA (LICSW)
Entity Type:Individual
Prefix:
First Name:MAIMA
Middle Name:
Last Name:FANT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MAIMA
Other - Middle Name:E
Other - Last Name:METZGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7550 FRANCE AVE S STE 220
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4762
Mailing Address - Country:US
Mailing Address - Phone:612-888-0313
Mailing Address - Fax:
Practice Address - Street 1:7550 FRANCE AVE S STE 220
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4762
Practice Address - Country:US
Practice Address - Phone:612-888-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1041C0700X
MN228481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN464974224OtherFEDERAL