Provider Demographics
NPI:1427267772
Name:WERTZ, FREDERICK J (PHD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
Last Name:WERTZ
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 1:423 FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-4037
Mailing Address - Country:US
Mailing Address - Phone:914-478-2050
Mailing Address - Fax:
Practice Address - Street 1:FORDHAM UNIVERSITY
Practice Address - Street 2:226B DEALY HALL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458
Practice Address - Country:US
Practice Address - Phone:718-817-3778
Practice Address - Fax:718-817-3785
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007465-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01449774Medicaid
NY01449774Medicaid