Provider Demographics
NPI:1609231711
Name:FADER, NANCY (MFT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:FADER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 12TH ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2948
Mailing Address - Country:US
Mailing Address - Phone:619-823-9782
Mailing Address - Fax:
Practice Address - Street 1:106 THORN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5629
Practice Address - Country:US
Practice Address - Phone:619-431-0046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95040171000000X, 106H00000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95040OtherCA BBS