Provider Demographics
NPI:1649340084
Name:FAHLSTROM, MARY ANN (MFT 47696)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:FAHLSTROM
Suffix:
Gender:F
Credentials:MFT 47696
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:FAHLSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:189 LIBERTY ST NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3682
Mailing Address - Country:US
Mailing Address - Phone:503-409-5086
Mailing Address - Fax:
Practice Address - Street 1:189 LIBERTY ST NE
Practice Address - Street 2:SUITE 202
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3682
Practice Address - Country:US
Practice Address - Phone:503-409-5086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0724106H00000X
CA47696106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist