Provider Demographics
NPI:1144636655
Name:WOHLBERG, SIMONE
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:WOHLBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 N LAKE DR APT 1A1
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-2569
Mailing Address - Country:US
Mailing Address - Phone:718-564-5575
Mailing Address - Fax:
Practice Address - Street 1:58 BIRCH ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4701
Practice Address - Country:US
Practice Address - Phone:732-597-3487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-13-14758103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst