Provider Demographics
NPI:1790234441
Name:FICHTELBERG, ADAM (BA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:FICHTELBERG
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 AGNES PL
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1411
Mailing Address - Country:US
Mailing Address - Phone:908-528-2266
Mailing Address - Fax:
Practice Address - Street 1:111 AGNES PL
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1411
Practice Address - Country:US
Practice Address - Phone:908-528-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7770003323713101Medicaid