Provider Demographics
NPI:1073884151
Name:WOLFENSTEIN, MIRIAM (PHD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:WOLFENSTEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-7242
Mailing Address - Country:US
Mailing Address - Phone:207-467-3115
Mailing Address - Fax:
Practice Address - Street 1:62 PORTLAND RD 42
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6650
Practice Address - Country:US
Practice Address - Phone:207-251-7147
Practice Address - Fax:888-858-8495
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical