Provider Demographics
NPI:1417579145
Name:WISHBOW, MARIANNE
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:WISHBOW
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 1:528 GILES AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NJ
Mailing Address - Zip Code:08846-2407
Mailing Address - Country:US
Mailing Address - Phone:732-857-7645
Mailing Address - Fax:
Practice Address - Street 1:1390 VALLEY RD
Practice Address - Street 2:
Practice Address - City:STIRLING
Practice Address - State:NJ
Practice Address - Zip Code:07980-1346
Practice Address - Country:US
Practice Address - Phone:908-809-9463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00240000101YA0400X
NJ37PC00717900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)