Provider Demographics
NPI:1275603284
Name:WIENER, ALICE ELEANOR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:ELEANOR
Last Name:WIENER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3104
Mailing Address - Country:US
Mailing Address - Phone:706-235-6990
Mailing Address - Fax:706-235-4985
Practice Address - Street 1:412 E 1ST ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3104
Practice Address - Country:US
Practice Address - Phone:706-235-6990
Practice Address - Fax:706-235-4985
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002326103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist