Provider Demographics
NPI:1801829064
Name:FAZELPOOR, GUITY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GUITY
Middle Name:
Last Name:FAZELPOOR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 EDISON ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1358
Mailing Address - Country:US
Mailing Address - Phone:973-904-0499
Mailing Address - Fax:
Practice Address - Street 1:246 EDISON ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1358
Practice Address - Country:US
Practice Address - Phone:973-904-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100362200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ016426Medicare ID - Type UnspecifiedPROVIDER NUMBER