Provider Demographics
NPI:1881638617
Name:WIEDENHOEFT, GEORGE THOMAS (LMSW)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:THOMAS
Last Name:WIEDENHOEFT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 PYLE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4456
Mailing Address - Country:US
Mailing Address - Phone:906-774-0522
Mailing Address - Fax:906-774-1570
Practice Address - Street 1:715 PYLE DR
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4456
Practice Address - Country:US
Practice Address - Phone:906-774-0522
Practice Address - Fax:906-774-1570
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010194911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
982471010011OtherPREFERRED ONE
MIGW019491OtherBCBS OF MI