Provider Demographics
NPI:1104254143
Name:FAHY, DIANE (MED, LPCA, NCC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:FAHY
Suffix:
Gender:F
Credentials:MED, LPCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 GRANDBRIDGE DR.
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-2753
Mailing Address - Country:US
Mailing Address - Phone:919-247-4703
Mailing Address - Fax:
Practice Address - Street 1:8390 SIX FORKS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3060
Practice Address - Country:US
Practice Address - Phone:919-247-4703
Practice Address - Fax:919-782-8731
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9844101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health