Healthcare Provider Details

I. General information

NPI: 1063847663
Provider Name (Legal Business Name): FADY PHILIP MICHAIL MA, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 PENNINGTON RD
EWING NJ
08638-1400
US

IV. Provider business mailing address

1440 RUSSELL RD
PAOLI PA
19301-1236
US

V. Phone/Fax

Practice location:
  • Phone: 610-644-6464
  • Fax: 610-981-6078
Mailing address:
  • Phone: 610-644-6464
  • Fax: 610-981-6078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37AC00124300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: