Provider Demographics
NPI:1851860985
Name:MANIFEST PSYCHOTHERAPY AND WELLNESS
Entity Type:Organization
Organization Name:MANIFEST PSYCHOTHERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:WIEDERSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:412-407-7642
Mailing Address - Street 1:7448 SCHOYER AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15218-2316
Mailing Address - Country:US
Mailing Address - Phone:412-425-2530
Mailing Address - Fax:
Practice Address - Street 1:1112 S BRADDOCK AVE STE 203
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15218-1262
Practice Address - Country:US
Practice Address - Phone:412-407-7642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty