Provider Demographics
NPI:1891819181
Name:FAHERTY, ELLEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:ORLEANS
Mailing Address - State:MA
Mailing Address - Zip Code:02653-0806
Mailing Address - Country:US
Mailing Address - Phone:607-769-0837
Mailing Address - Fax:
Practice Address - Street 1:45 S ORLEANS RD
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:MA
Practice Address - Zip Code:02653-2422
Practice Address - Country:US
Practice Address - Phone:607-769-0837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2016-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10307103TC2200X, 103TH0100X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool