Provider Demographics
NPI:1083272439
Name:FRASER, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FRASER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WILLOWDALE FARMS
Mailing Address - Street 2:
Mailing Address - City:CLAVERACK
Mailing Address - State:NY
Mailing Address - Zip Code:12513-5153
Mailing Address - Country:US
Mailing Address - Phone:347-404-0140
Mailing Address - Fax:
Practice Address - Street 1:81 NY-9H
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534
Practice Address - Country:US
Practice Address - Phone:347-404-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002468225A00000X, 221700000X
225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02850677Medicaid