Provider Demographics
NPI:1407863681
Name:WIEDEMAN, ROBERT J (LMHC------CADAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:WIEDEMAN
Suffix:
Gender:M
Credentials:LMHC------CADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 SHERMAN GRV
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:MA
Mailing Address - Zip Code:01562-1431
Mailing Address - Country:US
Mailing Address - Phone:508-885-9239
Mailing Address - Fax:508-860-1068
Practice Address - Street 1:72 JAQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2476
Practice Address - Country:US
Practice Address - Phone:508-421-4507
Practice Address - Fax:508-860-1068
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1492101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1492OtherLMHC