Provider Demographics
NPI:1437836558
Name:FEDDEMAN, MARY ALTA (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALTA
Last Name:FEDDEMAN
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 GUESS RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-1163
Mailing Address - Country:US
Mailing Address - Phone:919-360-4236
Mailing Address - Fax:
Practice Address - Street 1:1735 GUESS RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-1163
Practice Address - Country:US
Practice Address - Phone:919-360-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0192201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical