Provider Demographics
NPI:1508418203
Name:FANDRICH, ALYSE
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:FANDRICH
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 1:755 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0130
Mailing Address - Country:US
Mailing Address - Phone:912-367-4614
Mailing Address - Fax:912-367-9048
Practice Address - Street 1:755 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0130
Practice Address - Country:US
Practice Address - Phone:912-367-4614
Practice Address - Fax:912-367-9048
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010854101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional