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General NPI Number Information
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NPI Number | 1457518292
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Entity Type | Individual
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Provider Name | FABIAN SERGIO WANDER L.M.S.W.
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Gender | Male
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 03/15/2010
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Provider Practice Location Address
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Address Line | 6714 41ST AVE WOODSIDE CLINIC
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City | WOODSIDE
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State | NY
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Zip | 11377-3790
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Country | US
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Telephone | 917-568-3500
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Fax |
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Provider Business Mailing Address
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Address Line | 8309 35TH AVE A-22
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City | JACKSON HEIGHTS
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State | NY
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Zip | 11372-5370
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Country | US
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Telephone | 917-568-3500
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Fax |
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 075755
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License Number State | NY
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