Healthcare Provider Details

I. General information

NPI: 1255377891
Provider Name (Legal Business Name): RONALD L WIENS LMSW, ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19291 NORTHLINE RD
SOUTHGATE MI
48195-2220
US

IV. Provider business mailing address

19291 NORTHLINE RD
SOUTHGATE MI
48195-2220
US

V. Phone/Fax

Practice location:
  • Phone: 734-287-1500
  • Fax: 734-287-1660
Mailing address:
  • Phone: 734-287-1500
  • Fax: 734-287-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801014659
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801014659
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801014659
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6801014659
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: