Provider Demographics
NPI:1578640892
Name:FALLIG, ROBERTA ROSEN (PHD)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ROSEN
Last Name:FALLIG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 MOUNTAIN AVE # B
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-2407
Mailing Address - Country:US
Mailing Address - Phone:908-979-1144
Mailing Address - Fax:908-979-1068
Practice Address - Street 1:254 MOUNTAIN AVE # B
Practice Address - Street 2:SUITE 202
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-2407
Practice Address - Country:US
Practice Address - Phone:908-979-1144
Practice Address - Fax:908-979-1068
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3269103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJFA 729187Medicare ID - Type Unspecified