Provider Demographics
NPI:1801669825
Name:WIELAND, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WIELAND
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 1:104 DELANEY DR
Mailing Address - Street 2:
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036-5093
Mailing Address - Country:US
Mailing Address - Phone:303-257-6473
Mailing Address - Fax:
Practice Address - Street 1:104 DELANEY DR
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036-5093
Practice Address - Country:US
Practice Address - Phone:303-257-6473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13509565-2501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling