Provider Demographics
NPI:1053483529
Name:WYGAND, GLORIA J (LCSW)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:WYGAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 KRAMER DR
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-5407
Mailing Address - Country:US
Mailing Address - Phone:631-957-4828
Mailing Address - Fax:
Practice Address - Street 1:199 N WELLWOOD AVE
Practice Address - Street 2:SUITE #4
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4003
Practice Address - Country:US
Practice Address - Phone:631-957-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR027358-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR48381Medicare UPIN
NYN50411Medicare ID - Type Unspecified