Provider Demographics
NPI:1669479820
Name:WIESEL, SYD L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SYD
Middle Name:L
Last Name:WIESEL
Suffix:
Gender:F
Credentials:LCSW
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 1844
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-1844
Mailing Address - Country:US
Mailing Address - Phone:541-347-1134
Mailing Address - Fax:541-347-1134
Practice Address - Street 1:390 1ST ST SW
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9667
Practice Address - Country:US
Practice Address - Phone:541-347-1134
Practice Address - Fax:541-347-1134
Is Sole Proprietor?:No
Enumeration Date:2005-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1866 LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181466Medicaid
OR116328Medicare ID - Type Unspecified