Provider Demographics
NPI:1346663408
Name:FAHEY, KATHRYN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:FAHEY
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 1:66 SUNDALE DR
Mailing Address - Street 2:WINDHAM
Mailing Address - City:WINDHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06280-1231
Mailing Address - Country:US
Mailing Address - Phone:860-465-9087
Mailing Address - Fax:
Practice Address - Street 1:123 QUARRY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1247
Practice Address - Country:US
Practice Address - Phone:860-465-2620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0032301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1023191467Medicaid