Provider Demographics
NPI:1972739589
Name:FANFAN, SCHELLIE MICHELLE (LMHC, MS, EDS)
Entity Type:Individual
Prefix:
First Name:SCHELLIE
Middle Name:MICHELLE
Last Name:FANFAN
Suffix:
Gender:F
Credentials:LMHC, MS, EDS
Other - Prefix:MRS
Other - First Name:SCHELLIE
Other - Middle Name:MICHELLE
Other - Last Name:FANFAN-SISSOKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC, MS, EDS
Mailing Address - Street 1:PO BOX 585509
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32858-5509
Mailing Address - Country:US
Mailing Address - Phone:407-235-8151
Mailing Address - Fax:407-452-3474
Practice Address - Street 1:1617 E VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3740
Practice Address - Country:US
Practice Address - Phone:407-235-8151
Practice Address - Fax:407-452-3474
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8246101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691610498OtherMEDICAID WAIVER
FL691610496OtherMEDICAID WAIVER