Healthcare Provider Details

I. General information

NPI: 1689270746
Provider Name (Legal Business Name): MARYANN WOJCIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 N EASTON RD
GLENSIDE PA
19038-4310
US

IV. Provider business mailing address

PO BOX 1062
ROSLYN PA
19001-9062
US

V. Phone/Fax

Practice location:
  • Phone: 215-285-3688
  • Fax: 215-469-4987
Mailing address:
  • Phone: 215-285-3688
  • Fax: 215-469-4987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH004802
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: