Provider Demographics
NPI:1740348119
Name:PEDICIN, MICHAEL (PHD LPC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PEDICIN
Suffix:
Gender:M
Credentials:PHD LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 FOREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221
Mailing Address - Country:US
Mailing Address - Phone:609-927-2581
Mailing Address - Fax:
Practice Address - Street 1:310 NEW JERSEY AVENUE
Practice Address - Street 2:
Practice Address - City:ABSECON
Practice Address - State:NJ
Practice Address - Zip Code:08201-2413
Practice Address - Country:US
Practice Address - Phone:609-646-7162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00044200101YP2500X
PAPC002405101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional