Healthcare Provider Details

I. General information

NPI: 1497737902
Provider Name (Legal Business Name): KEVIN L. WIELAND PSY.D., HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 MAGNAVOX WAY SUITE 120
FORT WAYNE IN
46804-1565
US

IV. Provider business mailing address

1415 MAGNAVOX WAY SUITE 120
FORT WAYNE IN
46804-1565
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 TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041419A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: