Provider Demographics
NPI:1174925325
Name:FAJEN, MIEL NORWOOD (EDD)
Entity type:Individual
Prefix:
First Name:MIEL
Middle Name:NORWOOD
Last Name:FAJEN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 COUNTY ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12123-3132
Mailing Address - Country:US
Mailing Address - Phone:518-785-1341
Mailing Address - Fax:
Practice Address - Street 1:475 WATERVLIET SHAKER RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4622
Practice Address - Country:US
Practice Address - Phone:518-785-1341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020859103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist