Provider Demographics
NPI:1689028540
Name:PEGUERO, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:PEGUERO
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 1:1629 POPHAM AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-7215
Mailing Address - Country:US
Mailing Address - Phone:718-518-5097
Mailing Address - Fax:718-579-2605
Practice Address - Street 1:1629 POPHAM AVE FL 1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-7215
Practice Address - Country:US
Practice Address - Phone:718-518-5097
Practice Address - Fax:718-579-2605
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090947104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker