Provider Demographics
NPI:1447819610
Name:FEARON, RAY
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:FEARON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 NORTHUMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:EASTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-3298
Mailing Address - Country:US
Mailing Address - Phone:096-510-1012
Mailing Address - Fax:
Practice Address - Street 1:29 NORTHUMBERLAND DR
Practice Address - Street 2:
Practice Address - City:EASTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3298
Practice Address - Country:US
Practice Address - Phone:096-510-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00821000101YM0800X
PAPC011400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC011400OtherLPC LICENSE