Provider Demographics
NPI:1346662418
Name:WIEDEMAN, LAURA DAVIDOFF (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:DAVIDOFF
Last Name:WIEDEMAN
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 1:1303 JEFFERSON ST STE 600A
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-2473
Mailing Address - Country:US
Mailing Address - Phone:707-203-2447
Mailing Address - Fax:
Practice Address - Street 1:1303 JEFFERSON ST STE 600A
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-2473
Practice Address - Country:US
Practice Address - Phone:707-203-2447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008744103TC0700X
CAPSY26875103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical