Provider Demographics
NPI:1902991391
Name:WIESE-WAIBEL, MAUREEN (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:
Last Name:WIESE-WAIBEL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 RARITAN RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1710
Mailing Address - Country:US
Mailing Address - Phone:732-381-1600
Mailing Address - Fax:732-381-1644
Practice Address - Street 1:800 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1710
Practice Address - Country:US
Practice Address - Phone:732-381-1600
Practice Address - Fax:732-381-1644
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC047467001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ11235188OtherCAQH PROVIDER NO.
NJ141606OtherMEDICARE PTAN
NJ262135919OtherTAX ID CHANGE
NJ296033OtherMHN PROVIDER NUMBER
NJP2912168OtherOXFORD PROVIDER NUMBER