Provider Demographics
NPI:1821303843
Name:FERTUCK, ERIC A (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:FERTUCK
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 1:286 MADISON AVE
Mailing Address - Street 2:NEW YORK
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6345
Mailing Address - Country:US
Mailing Address - Phone:212-213-5088
Mailing Address - Fax:
Practice Address - Street 1:286 MADISON AVE
Practice Address - Street 2:NEW YORK
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6345
Practice Address - Country:US
Practice Address - Phone:212-213-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13946103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical