Provider Demographics
NPI:1104717438
Name:FAHERTY, SAM RAE
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:RAE
Last Name:FAHERTY
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RAE
Other - Last Name:FAHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6400 SOUTHCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2547
Mailing Address - Country:US
Mailing Address - Phone:206-901-2010
Mailing Address - Fax:
Practice Address - Street 1:16225 NE 87TH ST STE 160
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3536
Practice Address - Country:US
Practice Address - Phone:206-901-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor