Provider Demographics
NPI:1164743613
Name:FOFANOVA, LAUREN LOYAL (LCSW)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:LOYAL
Last Name:FOFANOVA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:LOYAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10255 AURORA RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1179
Mailing Address - Country:US
Mailing Address - Phone:713-203-6947
Mailing Address - Fax:
Practice Address - Street 1:1300 S YALE ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6328
Practice Address - Country:US
Practice Address - Phone:713-203-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX510071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical