Provider Demographics
NPI:1699110742
Name:FANNING, DEBRA (LCPC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:FANNING
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0604
Mailing Address - Country:US
Mailing Address - Phone:309-706-3190
Mailing Address - Fax:309-588-4115
Practice Address - Street 1:180 S MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-706-3190
Practice Address - Fax:309-588-4115
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003689101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional