MEDICARE: MS. CORY WEGESA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	44SC05492500	NJ

General Provider Information

NPI Number	:	1447751896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CORY WEGESA LCSW

Provider Business Mailing Address
First Line	:	101 FAIRWAY AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-1010
Country	:	US
Telephone Number	:	973-856-1906
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 FAIRWAY AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-1010
Country	:	US
Telephone Number	:	973-856-1906
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2018
Last Update Date	:	02/21/2018

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