Provider Demographics
NPI:1982825840
Name:WIEDERSPAHN, JOHN A (CMHW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:WIEDERSPAHN
Suffix:
Gender:M
Credentials:CMHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 LUCKY CT
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6100
Mailing Address - Country:US
Mailing Address - Phone:307-286-1733
Mailing Address - Fax:307-433-8785
Practice Address - Street 1:1901 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3759
Practice Address - Country:US
Practice Address - Phone:307-638-4092
Practice Address - Fax:307-433-8785
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCMHW-28101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health