Provider Demographics
NPI:1679827752
Name:WOLBERG, ILANA RACHEL (MSED)
Entity type:Individual
Prefix:
First Name:ILANA
Middle Name:RACHEL
Last Name:WOLBERG
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 BARNARD AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1701
Mailing Address - Country:US
Mailing Address - Phone:516-612-3757
Mailing Address - Fax:
Practice Address - Street 1:433 BARNARD AVE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1701
Practice Address - Country:US
Practice Address - Phone:516-612-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist