MEDICARE: DR. AMANDA MARIE DIVITA WIEMKEN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	06456	MD

General Provider Information

NPI Number	:	1043825151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA MARIE DIVITA WIEMKEN PSY.D.

Provider Business Mailing Address
First Line	:	2431 SOLOMONS ISLAND RD STE 200
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-3730
Country	:	US
Telephone Number	:	410-757-2077
Fax Number	:

Provider Business Practice Location Address
First Line	:	2431 SOLOMONS ISLAND RD STE 200
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-3730
Country	:	US
Telephone Number	:	410-757-2077
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2020
Last Update Date	:	02/21/2022

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