MEDICARE: DR. CAROL R. WENZEL-RIDEOUT PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	35SI00471300	NJ

General Provider Information

NPI Number	:	1760609515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL R. WENZEL-RIDEOUT PSY.D.

Provider Business Mailing Address
First Line	:	51 UPPER MONTCLAIR PLZ
Second Line	:	SUITE 17
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-1340
Country	:	US
Telephone Number	:	973-809-9755
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 UPPER MONTCLAIR PLZ
Second Line	:	SUITE 17
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-1340
Country	:	US
Telephone Number	:	973-809-9755
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	01/31/2011

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