Healthcare Provider Details

I. General information

NPI: 1477687812
Provider Name (Legal Business Name): FICTRE COUNSELING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HIGH STREET
MT. HOLLY NJ
08060
US

IV. Provider business mailing address

111 HIGH ST
MT. HOLLY NJ
08060
US

V. Phone/Fax

Practice location:
  • Phone: 856-573-7742
  • Fax:
Mailing address:
  • Phone: 856-573-7742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0059986
License Number StateNJ

VIII. Authorized Official

Name: EUGENE - WITHERSPOON
Title or Position: INTENSIVE WITHIN COMMUNITY PROVIDER
Credential: MASTER OF HUMAN SERV
Phone: 856-573-7742