Provider Demographics
NPI:1639235864
Name:WIESEN, NICOLE P (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:P
Last Name:WIESEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SARATOGA AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-3408
Mailing Address - Country:US
Mailing Address - Phone:408-273-6596
Mailing Address - Fax:408-249-9240
Practice Address - Street 1:920 SARATOGA AVE STE 212
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-3408
Practice Address - Country:US
Practice Address - Phone:408-273-6596
Practice Address - Fax:408-249-9240
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41199106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist