Provider Demographics
NPI:1427513092
Name:WEINER, MARK S (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:WEINER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 W END AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-1816
Mailing Address - Country:US
Mailing Address - Phone:908-432-2547
Mailing Address - Fax:
Practice Address - Street 1:328 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2456
Practice Address - Country:US
Practice Address - Phone:908-432-2547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4137103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1881922458OtherNPI
NJ1356532998OtherNPI