Healthcare Provider Details

I. General information

NPI: 1295094639
Provider Name (Legal Business Name): SHIRA WIESEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 HIGHPOINT RD SUITE B
BEACHWOOD OH
44122-6052
US

IV. Provider business mailing address

2451 BRENTWOOD RD
BEACHWOOD OH
44122-1550
US

V. Phone/Fax

Practice location:
  • Phone: 216-831-6611
  • Fax:
Mailing address:
  • Phone: 216-297-9477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6900
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: