Provider Demographics
NPI:1477279990
Name:BA, FANTA
Entity Type:Individual
Prefix:
First Name:FANTA
Middle Name:
Last Name:BA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 E LOOCKERMAN ST STE 309
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-8305
Mailing Address - Country:US
Mailing Address - Phone:302-734-2700
Mailing Address - Fax:
Practice Address - Street 1:9 E LOOCKERMAN ST STE 309
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-8305
Practice Address - Country:US
Practice Address - Phone:302-734-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ4-0010429104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker