Healthcare Provider Details

I. General information

NPI: 1275724924
Provider Name (Legal Business Name): NICOLE S FADER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICKY FADER LMT

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W PARK AVE SUITE 201
LONG BEACH NY
11561-3212
US

IV. Provider business mailing address

202 W PARK AVE SUITE 201
LONG BEACH NY
11561-3212
US

V. Phone/Fax

Practice location:
  • Phone: 516-606-5473
  • Fax:
Mailing address:
  • Phone: 516-606-5473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number015711-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: