Provider Demographics
NPI:1992771679
Name:WANDER, MARILYN R (PHD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:R
Last Name:WANDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3253 N BEND RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-7610
Mailing Address - Country:US
Mailing Address - Phone:513-662-9900
Mailing Address - Fax:513-662-9902
Practice Address - Street 1:3253 N BEND RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-7610
Practice Address - Country:US
Practice Address - Phone:513-622-9900
Practice Address - Fax:513-622-9902
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5564103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH87726OtherUBH
OH45020-0001OtherCARE SOURCE
OH2267792Medicaid
OHCP25303Medicare PIN