Provider Demographics
NPI:1699860148
Name:FAHERTY, REBECCA JEAN (LICSW, LADC1, C-SWHC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JEAN
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:LICSW, LADC1, C-SWHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 BELMONT STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02601
Mailing Address - Country:US
Mailing Address - Phone:508-583-4500
Mailing Address - Fax:774-826-2073
Practice Address - Street 1:940 BELMONT STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02601
Practice Address - Country:US
Practice Address - Phone:508-583-4500
Practice Address - Fax:774-826-2073
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1100101YA0400X
MA1146171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)