=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356547962
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WIELAND ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2007
-----------------------------------------------------
Last Update Date | 10/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 MAGNAVOX WAY STE: 120
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-1553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-483-7207
-----------------------------------------------------
Fax | 260-483-0836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1415 MAGNAVOX WAY STE:120
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-1553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-483-7207
-----------------------------------------------------
Fax | 260-483-0836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PSYCHOLOGIST
-----------------------------------------------------
Name | DR. KEVIN LEE WIELAND
-----------------------------------------------------
Credential | PSY.D., HSPP
-----------------------------------------------------
Telephone | 260-483-7207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 20041419A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------