Provider Demographics
NPI:1558081190
Name:FATAFEHI, CHARLOTTE ANN (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANN
Last Name:FATAFEHI
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 1:506 ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1421
Mailing Address - Country:US
Mailing Address - Phone:208-497-4806
Mailing Address - Fax:
Practice Address - Street 1:335 E MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1546
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:208-624-4030
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID88617311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical