Provider Demographics
NPI:1578901559
Name:WIESE, PAUL ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ROBERT
Last Name:WIESE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 N CHIPMAN ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-4901
Mailing Address - Country:US
Mailing Address - Phone:906-362-7726
Mailing Address - Fax:989-472-4110
Practice Address - Street 1:1116 N CHIPMAN ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-4901
Practice Address - Country:US
Practice Address - Phone:906-362-7726
Practice Address - Fax:989-472-4110
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV673103T00000X
MI6301008035103T00000X
FLFL EXEMPT 490.014103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst