Provider Demographics
NPI:1992819577
Name:FAHERTY, BRIAN F (PSYD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:F
Last Name:FAHERTY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 526
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01903
Mailing Address - Country:US
Mailing Address - Phone:781-596-2502
Mailing Address - Fax:781-596-3966
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901
Practice Address - Country:US
Practice Address - Phone:781-581-3900
Practice Address - Fax:781-598-8137
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6280103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral