Provider Demographics
NPI:1083002091
Name:WIANDT, MICHAEL (LSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WIANDT
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3445 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COVENTRY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:44319-3028
Mailing Address - Country:US
Mailing Address - Phone:330-644-4095
Mailing Address - Fax:330-645-2033
Practice Address - Street 1:3445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44319-3028
Practice Address - Country:US
Practice Address - Phone:330-644-4095
Practice Address - Fax:330-645-2033
Is Sole Proprietor?:No
Enumeration Date:2014-12-27
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 0012823104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0294091Medicaid