Healthcare Provider Details

I. General information

NPI: 1770188344
Provider Name (Legal Business Name): JOHN WYETZNER LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MAIN ST STE 200
MADISON NJ
07940-2370
US

IV. Provider business mailing address

333 MAIN ST STE 200
MADISON NJ
07940-2370
US

V. Phone/Fax

Practice location:
  • Phone: 646-457-0735
  • Fax:
Mailing address:
  • Phone: 646-457-0735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL06613000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: