Healthcare Provider Details

I. General information

NPI: 1225408867
Provider Name (Legal Business Name): TALIA WIESEL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 MADISON AVE
NEW YORK NY
10029-6514
US

IV. Provider business mailing address

1425 MADISON AVENUE
NEW YORK NY
10029
US

V. Phone/Fax

Practice location:
  • Phone: 212-659-8752
  • Fax: 212-996-8931
Mailing address:
  • Phone: 212-659-8752
  • Fax: 212-996-8931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number021240
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: