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General NPI Number Information
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NPI Number | 1033208319
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Entity Type | Individual
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Provider Name | TIMOTHY C. WIEDEL PHD
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Gender | Male
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 01/20/2012
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Provider Practice Location Address
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Address Line | 7251 W NORTH AVE SUITE 5
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City | WAUWATOSA
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State | WI
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Zip | 53213-1851
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Country | US
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Telephone | 414-248-2554
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Fax | 414-302-4620
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Provider Business Mailing Address
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Address Line | 7251 W NORTH AVE SUITE 5
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City | WAUWATOSA
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State | WI
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Zip | 53213-1851
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Country | US
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Telephone | 414-248-2554
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Fax | 414-302-4620
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 1227-057
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1227-057
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 103TM1800X
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Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
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License Number | 1227-057
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License Number State | WI
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