Provider Demographics
NPI:1063626380
Name:WIESNER, ERIC CARL (SLP)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:CARL
Last Name:WIESNER
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 OCEAN BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120-4441
Mailing Address - Country:US
Mailing Address - Phone:239-455-5705
Mailing Address - Fax:
Practice Address - Street 1:3490 OCEAN BLUFF CT
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34120-4441
Practice Address - Country:US
Practice Address - Phone:239-455-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7191235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist