Provider Demographics
NPI:1144313248
Name:FANE, ROBERT BRUCE (EDD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BRUCE
Last Name:FANE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 LEHMAN AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-6515
Mailing Address - Country:US
Mailing Address - Phone:270-393-9833
Mailing Address - Fax:270-393-9835
Practice Address - Street 1:1011 LEHMAN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-6515
Practice Address - Country:US
Practice Address - Phone:270-393-9833
Practice Address - Fax:270-393-9835
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1104103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent