Provider Demographics
NPI:1073948766
Name:FAHN, DAVID B
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:B
Last Name:FAHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12500 BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-9784
Mailing Address - Country:US
Mailing Address - Phone:916-874-1042
Mailing Address - Fax:
Practice Address - Street 1:12500 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-9784
Practice Address - Country:US
Practice Address - Phone:916-874-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CAASW676891041C0700X
CALCSW823921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker