Provider Demographics
NPI:1477630911
Name:WIENER, DONNA MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:WIENER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W NC HIGHWAY 54
Mailing Address - Street 2:STE 103
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5572
Mailing Address - Country:US
Mailing Address - Phone:919-354-0840
Mailing Address - Fax:919-748-4441
Practice Address - Street 1:6885 CLIFFDALE RD STE 202
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2834
Practice Address - Country:US
Practice Address - Phone:910-339-0400
Practice Address - Fax:910-339-0396
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3027103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000810Medicaid
NY046NCOtherBCBS PIN
NY046NCOtherBCBS PIN