Provider Demographics
NPI:1316299506
Name:FAHY, CAROLYN A (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:A
Last Name:FAHY
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 1:223 MIMOSA DR
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1334
Mailing Address - Country:US
Mailing Address - Phone:856-816-0280
Mailing Address - Fax:
Practice Address - Street 1:228 KINGS HWY EAST SUITE 101
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033
Practice Address - Country:US
Practice Address - Phone:856-216-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSCO52176001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ273844646OtherMAGELLAN
NJ273844646Medicaid
NJ273844646OtherMAGELLAN