Provider Demographics
NPI:1487673661
Name:WIESNER, JUDY K (MFT)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:K
Last Name:WIESNER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 541
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-0541
Mailing Address - Country:US
Mailing Address - Phone:916-215-5001
Mailing Address - Fax:
Practice Address - Street 1:31 NATOMA ST STE 110
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-2658
Practice Address - Country:US
Practice Address - Phone:916-215-5001
Practice Address - Fax:916-294-9701
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39756106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist