Provider Demographics
NPI:1497813299
Name:FAY, DEIRDRE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:FAY
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MAIN STREET
Mailing Address - Street 2:CTR INTEGRATIVE HEALING 2ND FLOOR
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472
Mailing Address - Country:US
Mailing Address - Phone:617-923-1930
Mailing Address - Fax:
Practice Address - Street 1:23 MAIN ST
Practice Address - Street 2:CTR INTEGRATIVE HEALING 2ND FLOOR
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4403
Practice Address - Country:US
Practice Address - Phone:617-923-1930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10308181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA406008OtherTUFTS HEALTH PLAN