Provider Demographics
NPI:1396095907
Name:FADDEN, ANITA ELLEN (LCAS-A)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:ELLEN
Last Name:FADDEN
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 W. 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101
Mailing Address - Country:US
Mailing Address - Phone:336-725-8389
Mailing Address - Fax:336-725-1061
Practice Address - Street 1:665 W. 4TH STREET
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101
Practice Address - Country:US
Practice Address - Phone:336-725-8389
Practice Address - Fax:336-725-1061
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor