Provider Demographics
NPI:1477302073
Name:WIEDER, LORI (LAPC, MED, NCC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WIEDER
Suffix:
Gender:F
Credentials:LAPC, MED, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 WESTERLY PKWY
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4227
Mailing Address - Country:US
Mailing Address - Phone:301-807-2245
Mailing Address - Fax:
Practice Address - Street 1:2023 CATO AVE STE 101
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2765
Practice Address - Country:US
Practice Address - Phone:814-308-8375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAPC000045101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional