Provider Demographics
NPI:1467714428
Name:WEIDMAN, MICHAEL JAMES II (MSW, LCSW, SAC-IT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:WEIDMAN
Suffix:II
Gender:M
Credentials:MSW, LCSW, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 E GATE DR
Mailing Address - Street 2:#46
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-8332
Mailing Address - Country:US
Mailing Address - Phone:414-519-7887
Mailing Address - Fax:
Practice Address - Street 1:10045 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2446
Practice Address - Country:US
Practice Address - Phone:414-358-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16604-130101YA0400X
WI8211-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)