Provider Demographics
NPI:1285180810
Name:WIESENFELD, BRACHA (LBA)
Entity Type:Individual
Prefix:
First Name:BRACHA
Middle Name:
Last Name:WIESENFELD
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BEAVER DAM RD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3204
Mailing Address - Country:US
Mailing Address - Phone:347-494-2170
Mailing Address - Fax:
Practice Address - Street 1:500 N FRANKLIN TPKE STE 311
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1160
Practice Address - Country:US
Practice Address - Phone:317-676-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY174400000X
NY001534103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist