Provider Demographics
NPI:1063994101
Name:FAHEY, CHRISTINE (LICSW)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:FAHEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1006
Mailing Address - Country:US
Mailing Address - Phone:617-771-7807
Mailing Address - Fax:
Practice Address - Street 1:35 ELM ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1006
Practice Address - Country:US
Practice Address - Phone:617-771-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10240311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical