Provider Demographics
NPI:1578332904
Name:FANNING, SANDRA C (PHD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:C
Last Name:FANNING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 W 19TH ST RM 3R
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4238
Mailing Address - Country:US
Mailing Address - Phone:786-244-7711
Mailing Address - Fax:
Practice Address - Street 1:5 W 19TH ST RM 3R
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4238
Practice Address - Country:US
Practice Address - Phone:786-244-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007917103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service