Provider Demographics
NPI:1942610720
Name:WIEDER, KAILA
Entity Type:Individual
Prefix:
First Name:KAILA
Middle Name:
Last Name:WIEDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ROSE GARDEN WAY UNIT 111
Mailing Address - Street 2:
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-7629
Mailing Address - Country:US
Mailing Address - Phone:845-426-0172
Mailing Address - Fax:
Practice Address - Street 1:360 NEW HEMPSTEAD RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-1926
Practice Address - Country:US
Practice Address - Phone:845-357-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12077759174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYEF24863VMedicaid