Provider Demographics
NPI:1295045706
Name:WIELGUS, MARK (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WIELGUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MERRICK RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2501
Mailing Address - Country:US
Mailing Address - Phone:800-725-6280
Mailing Address - Fax:800-725-6380
Practice Address - Street 1:141 DOSORIS LN
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1225
Practice Address - Country:US
Practice Address - Phone:516-676-1100
Practice Address - Fax:516-579-0216
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009602103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical