Healthcare Provider Details

I. General information

NPI: 1194138792
Provider Name (Legal Business Name): MAGGIE WANIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 GROVE ST APT 3
BLOOMFIELD NJ
07003-5641
US

IV. Provider business mailing address

75 GROVE ST
BLOOMFIELD NJ
07003-5641
US

V. Phone/Fax

Practice location:
  • Phone: 917-732-6942
  • Fax:
Mailing address:
  • Phone: 917-960-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: