Provider Demographics
NPI:1598143703
Name:WIEDER, DAVID (CMHC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WIEDER
Suffix:
Gender:M
Credentials:CMHC
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 1456
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84749-1456
Mailing Address - Country:US
Mailing Address - Phone:505-231-5031
Mailing Address - Fax:
Practice Address - Street 1:1764 W ASPEN LANE
Practice Address - Street 2:
Practice Address - City:LOA
Practice Address - State:UT
Practice Address - Zip Code:84747
Practice Address - Country:US
Practice Address - Phone:505-231-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT98506646009101YM0800X
101YM0800X
UT9850664-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health