Provider Demographics
NPI:1922476811
Name:DR. BETSY FERNBACH LLC
Entity Type:Organization
Organization Name:DR. BETSY FERNBACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:609-238-1751
Mailing Address - Street 1:1101 KINGS HWY N
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1912
Mailing Address - Country:US
Mailing Address - Phone:609-238-1751
Mailing Address - Fax:
Practice Address - Street 1:1101 KINGS HWY N
Practice Address - Street 2:SUITE 202
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1912
Practice Address - Country:US
Practice Address - Phone:609-238-1751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00225700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ125307Medicare PIN