Healthcare Provider Details

I. General information

NPI: 1184235046
Provider Name (Legal Business Name): CAROLYN ELISABETH WURST M.S.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 11/27/2023
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 W 127TH ST
NEW YORK NY
10027-3723
US

IV. Provider business mailing address

2259 27TH ST APT 3A
ASTORIA NY
11105-3138
US

V. Phone/Fax

Practice location:
  • Phone: 212-752-7575
  • Fax:
Mailing address:
  • Phone: 929-369-7563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3929313
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: