Provider Demographics
NPI:1952522633
Name:FANNON, DEBORAH JOYCE (LPC)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JOYCE
Last Name:FANNON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-1778
Mailing Address - Country:US
Mailing Address - Phone:660-582-3990
Mailing Address - Fax:
Practice Address - Street 1:902 EDMOND ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64501-2702
Practice Address - Country:US
Practice Address - Phone:816-232-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002011136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional