Provider Demographics
NPI:1962435321
Name:O'MEARA, MARY FAIRBANK (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:FAIRBANK
Last Name:O'MEARA
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 1:165 E DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-3011
Mailing Address - Country:US
Mailing Address - Phone:540-825-1215
Mailing Address - Fax:650-987-9444
Practice Address - Street 1:165 E DAVIS ST
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3011
Practice Address - Country:US
Practice Address - Phone:540-825-1215
Practice Address - Fax:650-987-9444
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040013861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA086605OtherSOUTHERN HEALTH
VA2993306OtherMAMSI
VAO86605OtherSENTARA
VA055399OtherANTHEM
VAJ6WCXBOtherWWT
VAA308770OtherVALUE OPTIONS
VAA308770OtherVALUE OPTIONS