Healthcare Provider Details

I. General information

NPI: 1972969319
Provider Name (Legal Business Name): JENNIFER FAITH WIENER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SEAVIEW AVE
STATEN ISLAND NY
10305-3409
US

IV. Provider business mailing address

26 DANIELLA CT
STATEN ISLAND NY
10314-7874
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-2600
  • Fax:
Mailing address:
  • Phone: 718-983-9050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number056399
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: