MEDICARE: MIRIAM WOHLBERG

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1770368714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM WOHLBERG

Provider Business Mailing Address
First Line	:	205 E 5TH ST
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-3414
Country	:	US
Telephone Number	:	732-675-0988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 AVENUE OF THE STATES
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-4789
Country	:	US
Telephone Number	:	732-961-7413
Fax Number	:

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

Provider Enumeration Date	:	08/28/2023
Last Update Date	:	08/28/2023

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