Provider Demographics
NPI:1700981396
Name:FANNING, LACONDA GERTRUDE (PSY,D, LPC)
Entity Type:Individual
Prefix:MRS
First Name:LACONDA
Middle Name:GERTRUDE
Last Name:FANNING
Suffix:
Gender:F
Credentials:PSY,D, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1765
Mailing Address - Country:US
Mailing Address - Phone:757-788-0300
Mailing Address - Fax:
Practice Address - Street 1:600 MEDICAL DR
Practice Address - Street 2:SUITE A & B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1769
Practice Address - Country:US
Practice Address - Phone:757-788-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003750101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010117241Medicaid
VA4945573Medicaid
VA4945573Medicaid