Basic Information
| Provider Information | |||||||||
| NPI: | 1770864092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEDORA | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 POMEROY TER | ||||||||
| Address2: | |||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010603378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135841310 | ||||||||
| FaxNumber: | 4135861496 | ||||||||
| Practice Location | |||||||||
| Address1: | 78 POMEROY TER | ||||||||
| Address2: | |||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010603378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135841310 | ||||||||
| FaxNumber: | 4135861496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2011 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.