Provider Demographics
NPI:1013120054
Name:FANNIN, MELISSA (LPCC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FANNIN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:3701 LANSDOWNE DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102
Practice Address - Country:US
Practice Address - Phone:606-324-3005
Practice Address - Fax:606-329-1530
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103173101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000532644OtherANTHEM BCBS (NON PAR)
000000532644OtherANTHEM BCBS
12656765OtherCAQH
KY7100280950Medicaid