Provider Demographics
NPI:1659410413
Name:WIEBOLDT, PATRICIA A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:WIEBOLDT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MARIAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BELLE MEAD
Mailing Address - State:NJ
Mailing Address - Zip Code:08502
Mailing Address - Country:US
Mailing Address - Phone:908-359-4670
Mailing Address - Fax:908-237-5435
Practice Address - Street 1:43 TAMARACK CIRCLE
Practice Address - Street 2:
Practice Address - City:SKILLMAN
Practice Address - State:NJ
Practice Address - Zip Code:08558
Practice Address - Country:US
Practice Address - Phone:908-359-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC003869001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI901681Medicare ID - Type Unspecified