Provider Demographics
NPI:1922421791
Name:FANNING, LAURA (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FANNING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E 2ND ST STE 102
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-4686
Mailing Address - Country:US
Mailing Address - Phone:631-682-7495
Mailing Address - Fax:
Practice Address - Street 1:21 E 2ND ST STE 102
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-4686
Practice Address - Country:US
Practice Address - Phone:631-682-7495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0904471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical