Provider Demographics
NPI:1194941682
Name:WIESE, STEVEN ROGER (LP)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:ROGER
Last Name:WIESE
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21211 IMPERIAL AVE N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-9547
Mailing Address - Country:US
Mailing Address - Phone:651-464-1121
Mailing Address - Fax:651-633-5238
Practice Address - Street 1:2780 SNELLING AVE N STE 104
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-7115
Practice Address - Country:US
Practice Address - Phone:651-633-5290
Practice Address - Fax:651-633-5238
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1426103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN04Q65WIOtherBCBSM NON PAR PROVIDER ID