Provider Demographics
NPI:1912546300
Name:FARGO, DANIELLE MARIE (MFT-INTERN)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:FARGO
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 AIRMOTIVE WAY STE 140
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3283
Mailing Address - Country:US
Mailing Address - Phone:775-737-9001
Mailing Address - Fax:775-870-1628
Practice Address - Street 1:1325 AIRMOTIVE WAY STE 140
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3283
Practice Address - Country:US
Practice Address - Phone:775-737-9001
Practice Address - Fax:775-870-1628
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI-1192106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist