Provider Demographics
NPI:1972592095
Name:FANCHER, MAEJEANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MAEJEANNE
Middle Name:
Last Name:FANCHER
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 1:109 PINE TER
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2883
Mailing Address - Country:US
Mailing Address - Phone:262-567-4948
Mailing Address - Fax:
Practice Address - Street 1:416 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-2755
Practice Address - Country:US
Practice Address - Phone:262-567-7673
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40938800Medicaid