Provider Demographics
NPI:1194916957
Name:FANNIN, BARBARA ELLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:ELLEN
Last Name:FANNIN
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 1:4929 WILSHIRE BLVD
Mailing Address - Street 2:SUITE NUMBER 510
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3808
Mailing Address - Country:US
Mailing Address - Phone:562-904-3999
Mailing Address - Fax:855-688-6746
Practice Address - Street 1:4929 WILSHIRE BLVD
Practice Address - Street 2:SUITE NUMBER 510
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3808
Practice Address - Country:US
Practice Address - Phone:562-904-3999
Practice Address - Fax:855-688-6746
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2021-03-18
Deactivation Date:2021-02-08
Deactivation Code:
Reactivation Date:2021-03-18
Provider Licenses
StateLicense IDTaxonomies
HI1050103T00000X
NY0172541103T00000X
NM1293103TC0700X
CAPSY26371103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist