Provider Demographics
NPI:1841076452
Name:FIDALGO, TINA F
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:F
Last Name:FIDALGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:986 LEONARDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07716-2713
Mailing Address - Country:US
Mailing Address - Phone:866-832-6260
Mailing Address - Fax:
Practice Address - Street 1:986 LEONARDVILLE RD
Practice Address - Street 2:
Practice Address - City:ATLANTIC HIGHLANDS
Practice Address - State:NJ
Practice Address - Zip Code:07716-2713
Practice Address - Country:US
Practice Address - Phone:866-832-6260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00571200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty