Provider Demographics
NPI:1003972167
Name:WIENER, ERIC SCOTT (PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:SCOTT
Last Name:WIENER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7353 W SAND LAKE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5258
Mailing Address - Country:US
Mailing Address - Phone:407-352-1155
Mailing Address - Fax:
Practice Address - Street 1:7353 W SAND LAKE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5258
Practice Address - Country:US
Practice Address - Phone:407-352-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4576103TP0814X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73856Medicare ID - Type Unspecified