Provider Demographics
NPI:1407876378
Name:WIENER, DANIEL J (PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:WIENER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 LONG PLAIN RD
Mailing Address - Street 2:
Mailing Address - City:LEVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:01054-9523
Mailing Address - Country:US
Mailing Address - Phone:413-548-9283
Mailing Address - Fax:
Practice Address - Street 1:836 FARMINGTON AVE
Practice Address - Street 2:SUITE 217 B
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1505
Practice Address - Country:US
Practice Address - Phone:860-490-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001293103T00000X
MA8086103T00000X
NY005193-1103T00000X
CT000281106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060001293CT01OtherANTHEM BCBS
CTD300000144Medicare PIN
MA0018347Medicare PIN
CT060001293CT01OtherANTHEM BCBS