Provider Demographics
NPI:1063018166
Name:FAY, PETER R (LICSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:FAY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SWINBURNE ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02835-1413
Mailing Address - Country:US
Mailing Address - Phone:401-227-7547
Mailing Address - Fax:
Practice Address - Street 1:1 SWINBURNE ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02835-1413
Practice Address - Country:US
Practice Address - Phone:401-339-9659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10262111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical