Provider Demographics
NPI:1760577266
Name:BOLTUCH-FAGAN, CANDACE ANN (LPC;LCADC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:ANN
Last Name:BOLTUCH-FAGAN
Suffix:
Gender:F
Credentials:LPC;LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1153
Mailing Address - Country:US
Mailing Address - Phone:201-986-7478
Mailing Address - Fax:
Practice Address - Street 1:2357 LEMOINE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024
Practice Address - Country:US
Practice Address - Phone:201-585-9814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0551101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional