Provider Demographics
NPI:1649398272
Name:FANNING, CYNTHIA A (MSW)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:FANNING
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:A
Other - Last Name:WIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:BACH HOSPITAL 650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR.
Practice Address - Street 2:BEHAVIORAL HEALTH
Practice Address - City:FORT CAMPBEL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:785-706-3409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC111501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME326450099OtherMAINE CARE NUMBER