Provider Demographics
NPI:1962548230
Name:FANT, JOHN LEE (CADC I)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LEE
Last Name:FANT
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 CHEMEKETA ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4145
Mailing Address - Country:US
Mailing Address - Phone:503-399-7400
Mailing Address - Fax:
Practice Address - Street 1:1095 25TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5049
Practice Address - Country:US
Practice Address - Phone:503-399-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06-07-55U101YA0400X
OR06-07055U171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator