Provider Demographics
NPI:1366212649
Name:WIELGUS, MIRIAM YAEL
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:YAEL
Last Name:WIELGUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 GREENBRIAR ST
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4226
Mailing Address - Country:US
Mailing Address - Phone:973-294-8816
Mailing Address - Fax:
Practice Address - Street 1:5 GREENTREE CTR
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3422
Practice Address - Country:US
Practice Address - Phone:973-692-8324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06516600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker