Provider Demographics
NPI:1639341126
Name:ROBERT FANE AGENCY, LLCP
Entity Type:Organization
Organization Name:ROBERT FANE AGENCY, LLCP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:FANE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:270-393-9833
Mailing Address - Street 1:1011 LEHMAN AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-6515
Mailing Address - Country:US
Mailing Address - Phone:270-393-9833
Mailing Address - Fax:270-393-9835
Practice Address - Street 1:1011 LEHMAN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-6515
Practice Address - Country:US
Practice Address - Phone:270-393-9833
Practice Address - Fax:270-393-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1104103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY29200912Medicaid
KY29100914Medicaid