Provider Demographics
NPI:1134747702
Name:FAHNESTOCK, VICTORIA LEIGH (LCSWA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEIGH
Last Name:FAHNESTOCK
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5543 SPINDLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-8535
Mailing Address - Country:US
Mailing Address - Phone:252-452-1023
Mailing Address - Fax:
Practice Address - Street 1:3604 SHANNON RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6343
Practice Address - Country:US
Practice Address - Phone:919-403-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP014882101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health