Healthcare Provider Details

I. General information

NPI: 1295941193
Provider Name (Legal Business Name): SUE ANNE WIEDENFELD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 E MADISON ST SUITE 201
SEATTLE WA
98112-4862
US

IV. Provider business mailing address

2808 E MADISON ST SUITE 201
SEATTLE WA
98112-4862
US

V. Phone/Fax

Practice location:
  • Phone: 206-323-6909
  • Fax: 206-324-0867
Mailing address:
  • Phone: 206-323-6909
  • Fax: 206-324-0867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1354
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: