Provider Demographics
NPI:1093938342
Name:WISHNER, JERRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:WISHNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-1339
Mailing Address - Country:US
Mailing Address - Phone:914-763-1140
Mailing Address - Fax:914-763-1140
Practice Address - Street 1:503 GRASSLANDS RD
Practice Address - Street 2:SUITE 107
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1503
Practice Address - Country:US
Practice Address - Phone:914-763-1140
Practice Address - Fax:914-763-1140
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012022-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist