Provider Demographics
NPI:1871713065
Name:WIGUTOW, DAWN MARIE
Entity type:Individual
Prefix:
First Name:DAWN MARIE
Middle Name:
Last Name:WIGUTOW
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 1:27 UHL ST
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2740
Mailing Address - Country:US
Mailing Address - Phone:631-877-9184
Mailing Address - Fax:
Practice Address - Street 1:27 UHL ST
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2740
Practice Address - Country:US
Practice Address - Phone:631-877-9184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076904-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical