Provider Demographics
NPI:1295094639
Name:WIESEN, SHIRA (PHD)
Entity type:Individual
Prefix:DR
First Name:SHIRA
Middle Name:
Last Name:WIESEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1550
Mailing Address - Country:US
Mailing Address - Phone:216-297-9477
Mailing Address - Fax:
Practice Address - Street 1:24800 HIGHPOINT RD
Practice Address - Street 2:SUITE B
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6052
Practice Address - Country:US
Practice Address - Phone:216-831-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical