Provider Demographics
NPI:1619680436
Name:WIEDER, AMY JILL
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JILL
Last Name:WIEDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JILL
Other - Last Name:SQUYRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 HOLLAND DR
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16002-7564
Mailing Address - Country:US
Mailing Address - Phone:724-282-1627
Mailing Address - Fax:
Practice Address - Street 1:901 E BRADY ST
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-4648
Practice Address - Country:US
Practice Address - Phone:724-282-1627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015176101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional