Provider Demographics
NPI:1710971064
Name:FADER, JONATHAN (PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:FADER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W 25TH ST FL 10
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7470
Mailing Address - Country:US
Mailing Address - Phone:212-335-2100
Mailing Address - Fax:646-775-4142
Practice Address - Street 1:138 W 25TH ST FL 10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7470
Practice Address - Country:US
Practice Address - Phone:212-335-2100
Practice Address - Fax:646-775-4142
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016156103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016156OtherLICENSE