Provider Demographics
NPI:1033215991
Name:WIESNER, LORI (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WIESNER
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-3630
Mailing Address - Country:US
Mailing Address - Phone:401-475-4199
Mailing Address - Fax:
Practice Address - Street 1:304 FRONT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-2425
Practice Address - Country:US
Practice Address - Phone:401-725-9400
Practice Address - Fax:401-725-9424
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW012631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI406304OtherBLUE CHIP
RILW59545Medicaid
RI30310-3OtherBLUE CROSS/BLUE SHIELD
RI62-32349OtherUNITED BEHAVIORAL HEALTH
RI1064580OtherNHP OF RI