Provider Demographics
NPI:1912111451
Name:FRIED, KEVIN L (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:FRIED
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MIDLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2806
Mailing Address - Country:US
Mailing Address - Phone:973-509-9620
Mailing Address - Fax:
Practice Address - Street 1:17 MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2806
Practice Address - Country:US
Practice Address - Phone:973-509-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100345100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist