Provider Demographics
NPI:1568945988
Name:FANTICH, JENNIFER LAUREN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:FANTICH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JENNIER
Other - Middle Name:LAUREN
Other - Last Name:SATOVSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:31815 SOUTHFIELD RD STE 11
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5471
Mailing Address - Country:US
Mailing Address - Phone:248-506-9867
Mailing Address - Fax:248-885-8270
Practice Address - Street 1:31815 SOUTHFIELD RD STE 11
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-506-9867
Practice Address - Fax:248-885-8270
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001348235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist