Provider Demographics
NPI:1205645389
Name:FANNIN, GEORGIA (LMSW)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:FANNIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CHINABERRY DR STE 900
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 E MARK ST
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2414
Practice Address - Country:US
Practice Address - Phone:318-240-7278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA182611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical