Provider Demographics
NPI:1871651851
Name:FRIEDMAN, MARK J (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:FRIEDMAN
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 1:72 OVERLOOK RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2021
Mailing Address - Country:US
Mailing Address - Phone:973-746-1176
Mailing Address - Fax:973-746-1176
Practice Address - Street 1:72 OVERLOOK RD
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-2021
Practice Address - Country:US
Practice Address - Phone:973-746-1176
Practice Address - Fax:973-746-1176
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1558706Medicaid
NJFR452614Medicare ID - Type Unspecified