Provider Demographics
NPI:1306954649
Name:WENDY FADER PHD PA
Entity type:Organization
Organization Name:WENDY FADER PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FADER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD PA
Authorized Official - Phone:561-362-5530
Mailing Address - Street 1:5295 TOWN CENTER RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1080
Mailing Address - Country:US
Mailing Address - Phone:561-362-5530
Mailing Address - Fax:561-362-5595
Practice Address - Street 1:5295 TOWN CENTER RD
Practice Address - Street 2:SUITE 401
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1080
Practice Address - Country:US
Practice Address - Phone:561-362-5530
Practice Address - Fax:561-362-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY004599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73916OtherBCBS FL
FLK4136Medicare ID - Type Unspecified
FL73916OtherBCBS FL
R99800Medicare UPIN