MEDICARE: CANDACE ANN BOLTUCH-FAGAN LPC;LCADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0551	NJ

General Provider Information

NPI Number	:	1760577266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDACE ANN BOLTUCH-FAGAN LPC;LCADC

Provider Business Mailing Address
First Line	:	177 COLONIAL RD
Second Line	:
City	:	EMERSON
State	:	NJ
Zip	:	07630-1153
Country	:	US
Telephone Number	:	201-986-7478
Fax Number	:

Provider Business Practice Location Address
First Line	:	2357 LEMOINE AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024
Country	:	US
Telephone Number	:	201-585-9814
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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