Provider Demographics
NPI:1689390981
Name:FANSHAW, BRODY THOMAS (MS, LPC-IT)
Entity Type:Individual
Prefix:MR
First Name:BRODY
Middle Name:THOMAS
Last Name:FANSHAW
Suffix:
Gender:M
Credentials:MS, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 5TH AVE S STE 523
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4018
Mailing Address - Country:US
Mailing Address - Phone:608-394-0698
Mailing Address - Fax:
Practice Address - Street 1:115 5TH AVE S STE 523
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4018
Practice Address - Country:US
Practice Address - Phone:608-394-0698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7151-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health