Provider Demographics
NPI:1043286636
Name:FANSLER, MARY ADRIENNE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ADRIENNE
Last Name:FANSLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ADRIENNE
Other - Last Name:FANSLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1787
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0261
Mailing Address - Country:US
Mailing Address - Phone:541-500-8655
Mailing Address - Fax:800-433-1396
Practice Address - Street 1:1237 N RIVERSIDE AVE
Practice Address - Street 2:SUITE 229
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-500-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL21171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR104832Medicare UPIN