Provider Demographics
NPI:1477971000
Name:WIESEN, NICOLE LYNNE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNNE
Last Name:WIESEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 DRUID OAKS NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3256
Mailing Address - Country:US
Mailing Address - Phone:404-603-6606
Mailing Address - Fax:
Practice Address - Street 1:214 DRUID OAKS NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3256
Practice Address - Country:US
Practice Address - Phone:404-603-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW3351101YM0800X
CA469104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health