Provider Demographics
NPI:1700662368
Name:FANNIN-FLETCHER, MOLLIE
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:FANNIN-FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 CITY LIGHTS ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-0186
Mailing Address - Country:US
Mailing Address - Phone:432-556-8897
Mailing Address - Fax:
Practice Address - Street 1:1660 OLD PECOS TRL STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4778
Practice Address - Country:US
Practice Address - Phone:505-657-9708
Practice Address - Fax:505-395-9295
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0675101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health