Provider Demographics
NPI:1821376328
Name:MIRON, WENDY (LMSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MIRON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:J
Other - Last Name:MIRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:189 JOHNSON AVE
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-2851
Mailing Address - Country:US
Mailing Address - Phone:718-581-3911
Mailing Address - Fax:
Practice Address - Street 1:4404 QUEENS BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2406
Practice Address - Country:US
Practice Address - Phone:718-706-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079434104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker