Healthcare Provider Details

I. General information

NPI: 1104600758
Provider Name (Legal Business Name): ROSE FEDECHKO LPC/COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 BRIDGETON PIKE STE 2
MANTUA NJ
08051-1318
US

IV. Provider business mailing address

PO BOX 366
MOUNT ROYAL NJ
08061-0366
US

V. Phone/Fax

Practice location:
  • Phone: 856-746-4244
  • Fax:
Mailing address:
  • Phone: 856-746-4244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC01223700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number46TA09094500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: