Provider Demographics
NPI:1902056914
Name:FADEL, IVONNE
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:FADEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 INDIAN FIELD DR
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07419-2435
Mailing Address - Country:US
Mailing Address - Phone:201-805-2999
Mailing Address - Fax:973-209-6230
Practice Address - Street 1:60 INDIAN FIELD DR
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NJ
Practice Address - Zip Code:07419-2435
Practice Address - Country:US
Practice Address - Phone:201-805-2999
Practice Address - Fax:973-209-6230
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00083400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0161691Medicaid