Provider Demographics
NPI:1144385824
Name:FERNBACH, BETSY ELLEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BETSY
Middle Name:ELLEN
Last Name:FERNBACH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 ROUTE 73
Mailing Address - Street 2:RAMBLEWOOD CENTER, SUITE 18
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2352
Mailing Address - Country:US
Mailing Address - Phone:856-273-0789
Mailing Address - Fax:
Practice Address - Street 1:1155 ROUTE 73
Practice Address - Street 2:RAMBLEWOOD CENTER, SUITE 18
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2352
Practice Address - Country:US
Practice Address - Phone:856-273-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00225700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ130367000OtherMAGELLAN MANAGED CARE