Provider Demographics
NPI:1578748406
Name:WIESE, LORENA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LORENA
Middle Name:
Last Name:WIESE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 72ND ST
Mailing Address - Street 2:#5J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4650
Mailing Address - Country:US
Mailing Address - Phone:212-744-9504
Mailing Address - Fax:
Practice Address - Street 1:420 E 72ND ST
Practice Address - Street 2:#5J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4650
Practice Address - Country:US
Practice Address - Phone:212-744-9504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076302-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical