Provider Demographics
NPI:1104600758
Name:FEDECHKO, ROSE LYNN MAE (LAC/COTA)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:LYNN MAE
Last Name:FEDECHKO
Suffix:
Gender:F
Credentials:LAC/COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HIGH STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062
Mailing Address - Country:US
Mailing Address - Phone:856-644-1300
Mailing Address - Fax:
Practice Address - Street 1:8 HIGH ST STE B
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-9540
Practice Address - Country:US
Practice Address - Phone:856-644-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health