Provider Demographics
NPI:1255476685
Name:FUDIN, CAROLE ELLEN (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:ELLEN
Last Name:FUDIN
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E 15TH ST
Mailing Address - Street 2:SUITE 1F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3531
Mailing Address - Country:US
Mailing Address - Phone:212-473-0932
Mailing Address - Fax:212-473-0932
Practice Address - Street 1:145 E 15TH ST
Practice Address - Street 2:SUITE 1F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3531
Practice Address - Country:US
Practice Address - Phone:212-473-0932
Practice Address - Fax:212-473-0932
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-012646-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR45190Medicare UPIN