Provider Demographics
NPI:1558081190
Name:FATAFEHI, CHARLOTTE ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANN
Last Name:FATAFEHI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1421
Mailing Address - Country:US
Mailing Address - Phone:208-497-4806
Mailing Address - Fax:
Practice Address - Street 1:335 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1546
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-42449104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker