Provider Demographics
NPI:1790184638
Name:FANNING, MICHAEL
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FANNING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9725 DECATUR DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-9656
Mailing Address - Country:US
Mailing Address - Phone:312-656-5489
Mailing Address - Fax:877-737-0499
Practice Address - Street 1:210 W OAK ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-2710
Practice Address - Country:US
Practice Address - Phone:404-734-6757
Practice Address - Fax:877-737-0499
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38300103TC0700X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No172A00000XOther Service ProvidersDriver