Provider Demographics
NPI:1811661242
Name:FONAREV, NIKITA
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:FONAREV
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:FONAREV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:20 RANDOLPH PL STE A
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4808
Mailing Address - Country:US
Mailing Address - Phone:347-668-0107
Mailing Address - Fax:
Practice Address - Street 1:20 RANDOLPH PL STE A
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4808
Practice Address - Country:US
Practice Address - Phone:347-668-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC064384001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical