MEDICARE: MRS. NICOLE P. WIESEN LMFT

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	106H00000X	Marriage & Family Therapist	MFC41199	CA

General Provider Information

NPI Number	:	1639235864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE P. WIESEN LMFT

Provider Business Mailing Address
First Line	:	920 SARATOGA AVE STE 212
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95129-3408
Country	:	US
Telephone Number	:	408-273-6596
Fax Number	:	408-249-9240

Provider Business Practice Location Address
First Line	:	920 SARATOGA AVE STE 212
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95129-3408
Country	:	US
Telephone Number	:	408-273-6596
Fax Number	:	408-249-9240

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

Provider Enumeration Date	:	12/30/2006
Last Update Date	:	07/08/2007

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