Doctor Name: | ERIC WESLEY FADELY |
NPI Number: | 1174819650 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MA MA |
License Number: | IMH 8755 |
Business Practice Address: | 3000 N Atlantic Ave Ste 102 Cocoa Beach, FL - 329315045 |
Business Phone Number: | 3217845367 |
Business Fax Number: | 3217832290 |
Mailing Address: | 3000 N Atlantic Ave Ste 102, COCOA BEACH |
State: | FL |
Postal Code: | 329315045 |
Phone Number: | 3217845367 |
Fax Number: | 3217832290 |
NPI Enumeration Date: | 06/23/2011 |
NPI Last Update Date: | 06/23/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | IMH 8755 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | FL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |