Basic Information
| Provider Information | |||||||||
| NPI: | 1346468964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANUCCHI | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2704 I ST NE | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980022411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538337444 | ||||||||
| FaxNumber: | 2537354111 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 W GOWE ST | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980325892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535209350 | ||||||||
| FaxNumber: | 2537354111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW00006266 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.