Basic Information
| Provider Information | |||||||||
| NPI: | 1780197657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANNIN | ||||||||
| FirstName: | TERRA | ||||||||
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| Credential: | LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 923 FINDLAY ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624148 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4350 GALLIA ST | ||||||||
| Address2: | |||||||||
| City: | NEW BOSTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456625515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546685 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2017 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 161402 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.