Provider Demographics
NPI:1841427663
Name:FRADKOV, VALERY EUGENE (LCSW)
Entity Type:Individual
Prefix:
First Name:VALERY
Middle Name:EUGENE
Last Name:FRADKOV
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-3214
Mailing Address - Country:US
Mailing Address - Phone:917-582-1683
Mailing Address - Fax:
Practice Address - Street 1:3100 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:917-582-1683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053911001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical