Healthcare Provider Details

I. General information

NPI: 1891819181
Provider Name (Legal Business Name): ELLEN FAHERTY PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 S ORLEANS RD
ORLEANS MA
02653-2422
US

IV. Provider business mailing address

PO BOX 806
ORLEANS MA
02653-0806
US

V. Phone/Fax

Practice location:
  • Phone: 607-769-0837
  • Fax:
Mailing address:
  • Phone: 607-769-0837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number10307
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number10307
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10307
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: