Provider Demographics
NPI:1568204063
Name:FANCHER, BRANDY
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:FANCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 ALDRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0845
Mailing Address - Country:US
Mailing Address - Phone:386-785-9972
Mailing Address - Fax:
Practice Address - Street 1:435 S RIDGEWOOD AVE STE 204C-205
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4927
Practice Address - Country:US
Practice Address - Phone:386-747-6541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW204631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical