Provider Demographics
NPI:1922472554
Name:WIEDER, BONNIE (MA, CAS)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:
Last Name:WIEDER
Suffix:
Gender:F
Credentials:MA, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4544
Mailing Address - Country:US
Mailing Address - Phone:518-761-2025
Mailing Address - Fax:518-761-2035
Practice Address - Street 1:13 LOCUST ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4544
Practice Address - Country:US
Practice Address - Phone:518-761-2025
Practice Address - Fax:518-761-2035
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool