Provider Demographics
NPI:1265013197
Name:WIEDEMANN, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:WIEDEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SADDLE LN
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2512
Mailing Address - Country:US
Mailing Address - Phone:646-351-2937
Mailing Address - Fax:
Practice Address - Street 1:191 BETHPAGE SWEET HOLLOW RD
Practice Address - Street 2:
Practice Address - City:OLD BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11804-1342
Practice Address - Country:US
Practice Address - Phone:516-870-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106818104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker