Healthcare Provider Details

I. General information

NPI: 1033208319
Provider Name (Legal Business Name): TIMOTHY C. WIEDEL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7251 W NORTH AVE SUITE 5
WAUWATOSA WI
53213-1851
US

IV. Provider business mailing address

7251 W NORTH AVE SUITE 5
WAUWATOSA WI
53213-1851
US

V. Phone/Fax

Practice location:
  • Phone: 414-248-2554
  • Fax: 414-302-4620
Mailing address:
  • Phone: 414-248-2554
  • Fax: 414-302-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1227-057
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1227-057
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number1227-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: