Provider Demographics
NPI:1881904217
Name:FANTLE, MARY LOUISE (LM&FT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:FANTLE
Suffix:
Gender:F
Credentials:LM&FT
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:FANTLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LM&FT
Mailing Address - Street 1:15798 E. PRENTICE DR.
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:TX
Mailing Address - Zip Code:80015-4268
Mailing Address - Country:US
Mailing Address - Phone:303-901-3313
Mailing Address - Fax:
Practice Address - Street 1:15798 E. PRENTICE DR.
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:TX
Practice Address - Zip Code:80015-4268
Practice Address - Country:US
Practice Address - Phone:303-901-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO927106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist