Provider Demographics
NPI:1619450426
Name:FANOLIS, VERBA S (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:VERBA
Middle Name:S
Last Name:FANOLIS
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1634
Mailing Address - Country:US
Mailing Address - Phone:413-348-8291
Mailing Address - Fax:
Practice Address - Street 1:1170 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2055
Practice Address - Country:US
Practice Address - Phone:413-750-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1139741041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool