Provider Demographics
NPI:1992826218
Name:WEINER, ERIC (MSW PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WEINER
Suffix:
Gender:M
Credentials:MSW PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3465
Mailing Address - Country:US
Mailing Address - Phone:262-241-7778
Mailing Address - Fax:262-241-1012
Practice Address - Street 1:11501 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3465
Practice Address - Country:US
Practice Address - Phone:262-241-7778
Practice Address - Fax:262-241-1012
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3298-1231041C0700X
WI143-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1041002Medicare PIN
WI000344745Medicare PIN