Provider Demographics
NPI:1912223454
Name:FANTO, ROBERT CORY (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CORY
Last Name:FANTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WEST MAPLE STREET
Mailing Address - Street 2:P O BOX 800
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0800
Mailing Address - Country:US
Mailing Address - Phone:509-565-4000
Mailing Address - Fax:505-565-7015
Practice Address - Street 1:800 WEST MAPLE STREET
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-0800
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:505-565-7015
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60127865103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist