Provider Demographics
NPI:1780648154
Name:FELLIN, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FELLIN
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 1:33 E NORTHAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-2406
Mailing Address - Country:US
Mailing Address - Phone:570-829-3489
Mailing Address - Fax:570-829-7781
Practice Address - Street 1:33 E NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-2406
Practice Address - Country:US
Practice Address - Phone:570-829-3489
Practice Address - Fax:570-829-7781
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0125491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA70381OtherGEISINGER HEALTH PLAN
PA2102769OtherCIGNA BEHAVIORAL HEALTH
PA70381OtherGEISINGER HEALTH PLAN