Healthcare Provider Details

I. General information

NPI: 1356547962
Provider Name (Legal Business Name): WIELAND ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 MAGNAVOX WAY STE: 120
FORT WAYNE IN
46804-1553
US

IV. Provider business mailing address

1415 MAGNAVOX WAY STE:120
FORT WAYNE IN
46804-1553
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041419A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIN

VIII. Authorized Official

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