Provider Demographics
NPI:1063894210
Name:FADEM, ANNA (MFTI)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:FADEM
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3845 SPRING DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1030
Mailing Address - Country:US
Mailing Address - Phone:618-515-2380
Mailing Address - Fax:
Practice Address - Street 1:823 GATEWAY CENTER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4541
Practice Address - Country:US
Practice Address - Phone:619-515-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2017-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist