Provider Demographics
NPI:1033208319
Name:WIEDEL, TIMOTHY C (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:C
Last Name:WIEDEL
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 1:7251 W NORTH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1851
Mailing Address - Country:US
Mailing Address - Phone:414-248-2554
Mailing Address - Fax:414-302-4620
Practice Address - Street 1:7251 W NORTH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1851
Practice Address - Country:US
Practice Address - Phone:414-248-2554
Practice Address - Fax:414-302-4620
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1227-057103G00000X, 103TC0700X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39071000Medicaid