Provider Demographics
NPI:1457518292
Name:WANDER, FABIAN SERGIO (LMSW)
Entity Type:Individual
Prefix:MR
First Name:FABIAN
Middle Name:SERGIO
Last Name:WANDER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 35TH AVE
Mailing Address - Street 2:A-22
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5370
Mailing Address - Country:US
Mailing Address - Phone:917-568-3500
Mailing Address - Fax:
Practice Address - Street 1:6714 41ST AVE
Practice Address - Street 2:WOODSIDE CLINIC
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3790
Practice Address - Country:US
Practice Address - Phone:917-568-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075755104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker