Provider Demographics
NPI:1366683856
Name:FENNELLY, MARY ELIZABETH (CRC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:FENNELLY
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 W. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945
Mailing Address - Country:US
Mailing Address - Phone:973-543-5656
Mailing Address - Fax:
Practice Address - Street 1:80 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:MENDHAM
Practice Address - State:NJ
Practice Address - Zip Code:07945
Practice Address - Country:US
Practice Address - Phone:973-543-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health