Provider Demographics
NPI:1578090759
Name:FANNIN, REBECCA MICHELLE (CT, LCDC III)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MICHELLE
Last Name:FANNIN
Suffix:
Gender:F
Credentials:CT, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1334
Mailing Address - Country:US
Mailing Address - Phone:740-592-6724
Mailing Address - Fax:
Practice Address - Street 1:120 TWIN OAKS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9506
Practice Address - Country:US
Practice Address - Phone:740-570-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161451101YA0400X
OHC.2002694-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1578090759Medicaid