Provider Demographics
NPI:1487719977
Name:FACHTING, DANIEL DEAN (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:DEAN
Last Name:FACHTING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1547
Mailing Address - Country:US
Mailing Address - Phone:989-386-8166
Mailing Address - Fax:
Practice Address - Street 1:301 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1547
Practice Address - Country:US
Practice Address - Phone:989-386-8166
Practice Address - Fax:989-386-8166
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008802103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11275836OtherCAQH
MI680A810140OtherBLUE CROSS BLUE SHIELD PI
MI251479000OtherMAGELLAN PIN
MI680A810140OtherBLUE CROSS BLUE SHIELD PI