Provider Demographics
NPI:1295819696
Name:FAHRENHOLZ, DONNA M (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:M
Last Name:FAHRENHOLZ
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 WINTERHALL RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2891
Mailing Address - Country:US
Mailing Address - Phone:716-662-3865
Mailing Address - Fax:716-662-7878
Practice Address - Street 1:70 BARKER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-2013
Practice Address - Country:US
Practice Address - Phone:716-883-1914
Practice Address - Fax:716-883-7637
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0261451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00688211Medicaid