Healthcare Provider Details

I. General information

NPI: 1982933925
Provider Name (Legal Business Name): DANA MARIE WEIDEMAN M.S.,L.L.P.,B.C.B.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18635 BOWIE ST
SOUTHGATE MI
48195-2805
US

IV. Provider business mailing address

18635 BOWIE ST
SOUTHGATE MI
48195-2805
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7700
  • Fax:
Mailing address:
  • Phone: 734-785-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number6301009563
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301009563
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: