Provider Demographics
NPI:1073793659
Name:WIENER, DIANE (SLP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WIENER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 STEEPLECHASE DR
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-1909
Mailing Address - Country:US
Mailing Address - Phone:732-308-9577
Mailing Address - Fax:732-308-1417
Practice Address - Street 1:2534 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3702
Practice Address - Country:US
Practice Address - Phone:718-777-5243
Practice Address - Fax:718-777-5250
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004518-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist