Healthcare Provider Details

I. General information

NPI: 1114341559
Provider Name (Legal Business Name): WIELAND & ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11123 PARKVIEW PLAZA DR SUITE 200
FORT WAYNE IN
46845
US

IV. Provider business mailing address

1415 MAGNAVOX WAY SUITE 120
FORT WAYNE IN
46804-1553
US

V. Phone/Fax

Practice location:
  • Phone: 260-672-6510
  • Fax: 260-672-6501
Mailing address:
  • Phone: 260-483-7207
  • Fax: 260-483-0836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20041419A
License Number StateIN

VIII. Authorized Official

Name: DR. KEVIN LEE WIELAND
Title or Position: PRESIDENT
Credential: PSY. D., HSPP
Phone: 260-483-7207