Provider Demographics
NPI:1720457187
Name:WIMBUSH, FREDERICK (CASAC)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:WIMBUSH
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-8908
Mailing Address - Country:US
Mailing Address - Phone:212-533-8400
Mailing Address - Fax:212-763-0699
Practice Address - Street 1:8 E 3RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-8908
Practice Address - Country:US
Practice Address - Phone:212-533-8400
Practice Address - Fax:212-763-0699
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20462171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20462OtherCASAC