Provider Demographics
NPI:1275801300
Name:WACHTEL, MARYANN CAROL
Entity Type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:CAROL
Last Name:WACHTEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BAXTER RD
Mailing Address - Street 2:
Mailing Address - City:AVERILL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12018-2401
Mailing Address - Country:US
Mailing Address - Phone:518-674-5325
Mailing Address - Fax:
Practice Address - Street 1:10 EMPIRE STATE BLVD
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9751
Practice Address - Country:US
Practice Address - Phone:518-477-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-04
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2604838251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)