Provider Demographics
NPI:1508167974
Name:FRY, THERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FRY
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 1:100 SHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:570-671-0300
Mailing Address - Fax:570-671-0305
Practice Address - Street 1:624 W CENTRE ST
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:PA
Practice Address - Zip Code:17976-1403
Practice Address - Country:US
Practice Address - Phone:570-671-0300
Practice Address - Fax:570-671-0305
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CW0184541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA394840X8SMedicare UPIN