Provider Demographics
NPI:1801030168
Name:FAHY, SHANNON C (MSW LCSW LICSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:FAHY
Suffix:
Gender:F
Credentials:MSW LCSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 BARNESWYCK DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2277
Mailing Address - Country:US
Mailing Address - Phone:919-839-9721
Mailing Address - Fax:984-444-4760
Practice Address - Street 1:637 BARNESWYCK DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2277
Practice Address - Country:US
Practice Address - Phone:919-839-9721
Practice Address - Fax:919-440-4760
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2025-09-17
Deactivation Date:2024-09-11
Deactivation Code:
Reactivation Date:2024-09-26
Provider Licenses
StateLicense IDTaxonomies
WY6961041C0700X
WALW616137571041C0700X
NCC0136481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1801030168Medicaid
NC453732Medicaid