Basic Information
| Provider Information | |||||||||
| NPI: | 1063639821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHRENKRUG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 610 MILL CREEK LN | ||||||||
| Address2: | APT 234 | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475461169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124823020 | ||||||||
| FaxNumber: | 8124826409 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 EVERSMAN DR | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475463548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124823020 | ||||||||
| FaxNumber: | 8124826409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34005322A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 34005322A | 01 | IN | LICENSE | OTHER |