Provider Demographics
NPI:1063639821
Name:FAHRENKRUG, MARY B (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:FAHRENKRUG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:NOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:610 MILL CREEK LN
Mailing Address - Street 2:APT 234
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1169
Mailing Address - Country:US
Mailing Address - Phone:812-482-3020
Mailing Address - Fax:812-482-6409
Practice Address - Street 1:480 EVERSMAN DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-3548
Practice Address - Country:US
Practice Address - Phone:812-482-3020
Practice Address - Fax:812-482-6409
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005322A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34005322AOtherLICENSE