Healthcare Provider Details

I. General information

NPI: 1467714428
Provider Name (Legal Business Name): MICHAEL JAMES WEIDMAN II MSW, LCSW, SAC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10045 W LISBON AVE
WAUWATOSA WI
53222-2446
US

IV. Provider business mailing address

346 E GATE DR #46
HARTFORD WI
53027-8332
US

V. Phone/Fax

Practice location:
  • Phone: 414-358-7144
  • Fax:
Mailing address:
  • Phone: 414-519-7887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16604-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8211-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: