Provider Demographics
NPI:1700245180
Name:FAIR, MARY L (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:FAIR
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 1:2223 S COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-3808
Mailing Address - Country:US
Mailing Address - Phone:848-333-5455
Mailing Address - Fax:
Practice Address - Street 1:600 HAVERFORD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1139
Practice Address - Country:US
Practice Address - Phone:610-664-2524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0187021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical