Provider Demographics
NPI:1417584145
Name:WIEDEMANN, TRENT MATTHEW
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:MATTHEW
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 1:478 S JOHNSON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2238
Mailing Address - Country:US
Mailing Address - Phone:504-412-1580
Mailing Address - Fax:
Practice Address - Street 1:478 S JOHNSON ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2238
Practice Address - Country:US
Practice Address - Phone:504-412-1580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3347532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty