Basic Information
| Provider Information | |||||||||
| NPI: | 1699860148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHERTY | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LICSW, LADC1, C-SWHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 BELMONT STREET | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085834500 | ||||||||
| FaxNumber: | 7748262073 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 BELMONT STREET | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085834500 | ||||||||
| FaxNumber: | 7748262073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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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 | 101YA0400X | 1100 | MA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 114617 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.