Provider Demographics
NPI:1174819650
Name:FADELY, ERIC WESLEY (MA MA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WESLEY
Last Name:FADELY
Suffix:
Gender:M
Credentials:MA MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N ATLANTIC AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-5045
Mailing Address - Country:US
Mailing Address - Phone:321-784-5367
Mailing Address - Fax:321-783-2290
Practice Address - Street 1:3000 N ATLANTIC AVE STE 102
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5045
Practice Address - Country:US
Practice Address - Phone:321-784-5367
Practice Address - Fax:321-783-2290
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 8755101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health