Provider Demographics
NPI:1215286273
Name:FORTENBERRY, CAROLYN M (LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 NEW DEHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2742
Mailing Address - Country:US
Mailing Address - Phone:610-635-5677
Mailing Address - Fax:610-828-4910
Practice Address - Street 1:20 E 2ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-1880
Practice Address - Country:US
Practice Address - Phone:610-635-5677
Practice Address - Fax:610-828-4910
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0168321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical