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General NPI Number Information
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NPI Number | 1295045706
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Entity Type | Individual
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Provider Name | MARK WIELGUS PH.D.
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Gender | Male
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Dates
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Enumeration Date | 10/18/2010
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Last Update Date | 10/18/2010
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Provider Practice Location Address
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Address Line | 141 DOSORIS LN
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City | GLEN COVE
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State | NY
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Zip | 11542-1225
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Country | US
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Telephone | 516-676-1100
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Fax | 516-579-0216
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Provider Business Mailing Address
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Address Line | 303 MERRICK RD SUITE 204
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City | LYNBROOK
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State | NY
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Zip | 11563-2501
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Country | US
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Telephone | 800-725-6280
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Fax | 800-725-6380
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 009602
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License Number State | NY
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