Provider Demographics
NPI:1063790509
Name:WIEDEMANN, TERESA (LICSW)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:
Last Name:WIEDEMANN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 RUSSET RD
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-8253
Mailing Address - Country:US
Mailing Address - Phone:509-520-4370
Mailing Address - Fax:
Practice Address - Street 1:139 RUSSET RD
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-8253
Practice Address - Country:US
Practice Address - Phone:509-520-4370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 601113771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical