Provider Demographics
NPI:1477616670
Name:FAHERTY, KAREN MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:MICHELLE
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MAPLE AVE
Mailing Address - Street 2:5B
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1734
Mailing Address - Country:US
Mailing Address - Phone:732-747-9221
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE AVE
Practice Address - Street 2:5B
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1734
Practice Address - Country:US
Practice Address - Phone:732-747-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4362103G00000X, 103TH0100X, 103TR0400X
NY0132182103T00000X
NY0131282103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0132182Medicare UPIN