Provider Demographics
NPI:1013564079
Name:MARY ELLEN FASSNACHT
Entity type:Organization
Organization Name:MARY ELLEN FASSNACHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:FASSNACHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-722-9831
Mailing Address - Street 1:317 GODWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 RTE 23
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:NJ
Practice Address - Zip Code:07405-2037
Practice Address - Country:US
Practice Address - Phone:973-722-9831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty