Provider Demographics
NPI:1467549964
Name:WIEDEMANN, KENNETH MAXIM (PHD PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MAXIM
Last Name:WIEDEMANN
Suffix:
Gender:M
Credentials:PHD PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14771 PLAZA DR STE L
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-8012
Mailing Address - Country:US
Mailing Address - Phone:714-731-1995
Mailing Address - Fax:714-669-8135
Practice Address - Street 1:14771 PLAZA DR STE L
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-8012
Practice Address - Country:US
Practice Address - Phone:714-731-1995
Practice Address - Fax:714-669-8135
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17821103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist