Provider Demographics
NPI:1992126494
Name:FAUTZ, ANNA
Entity type:Individual
Prefix:MS
First Name:ANNA
Middle Name:
Last Name:FAUTZ
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 1:100 PRISON RD
Mailing Address - Street 2:
Mailing Address - City:REPRESA
Mailing Address - State:CA
Mailing Address - Zip Code:95671-3000
Mailing Address - Country:US
Mailing Address - Phone:916-985-8610
Mailing Address - Fax:
Practice Address - Street 1:100 PRISON RD
Practice Address - Street 2:
Practice Address - City:REPRESA
Practice Address - State:CA
Practice Address - Zip Code:95671-3000
Practice Address - Country:US
Practice Address - Phone:916-985-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA328401041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical