Provider Demographics
NPI:1801030168
Name:FAHY, SHANNON C (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:FAHY
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 RAWLINS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1900
Mailing Address - Country:US
Mailing Address - Phone:307-426-4798
Mailing Address - Fax:
Practice Address - Street 1:4025 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1900
Practice Address - Country:US
Practice Address - Phone:307-426-4798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1801030168Medicaid