Provider Demographics
NPI:1275724924
Name:FADER, NICOLE S (LMT)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:S
Last Name:FADER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:NICKY
Other - Middle Name:
Other - Last Name:FADER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:202 W PARK AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3212
Mailing Address - Country:US
Mailing Address - Phone:516-606-5473
Mailing Address - Fax:
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3212
Practice Address - Country:US
Practice Address - Phone:516-606-5473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015711-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist