Provider Demographics
NPI:1952482267
Name:WIEDHOLZ-ABBOTT, LEESA MARIE (PSYD)
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:MARIE
Last Name:WIEDHOLZ-ABBOTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LEESA
Other - Middle Name:MARIE
Other - Last Name:WIEDHOLZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:815 NORTHDALE DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-2759
Mailing Address - Country:US
Mailing Address - Phone:262-752-4205
Mailing Address - Fax:
Practice Address - Street 1:3734 7TH AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5525
Practice Address - Country:US
Practice Address - Phone:262-654-9370
Practice Address - Fax:262-654-9379
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2352-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical