Healthcare Provider Details

I. General information

NPI: 1992771679
Provider Name (Legal Business Name): MARILYN R WANDER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3253 N BEND RD
CINCINNATI OH
45239-7610
US

IV. Provider business mailing address

3253 N BEND RD
CINCINNATI OH
45239-7610
US

V. Phone/Fax

Practice location:
  • Phone: 513-622-9900
  • Fax: 513-622-9902
Mailing address:
  • Phone: 513-662-9900
  • Fax: 513-662-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5564
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number5564
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: