Provider Demographics
NPI:1700484151
Name:WAXENBERG, FRED RONALD
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:RONALD
Last Name:WAXENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 HEWLETT AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-5312
Mailing Address - Country:US
Mailing Address - Phone:516-987-2351
Mailing Address - Fax:
Practice Address - Street 1:3001 HEWLETT AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-5312
Practice Address - Country:US
Practice Address - Phone:516-987-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0006472103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling