Provider Demographics
NPI:1215472824
Name:WIEBER, CHAD LOUIS
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:LOUIS
Last Name:WIEBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4134 CAMBOT CT NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-1100
Mailing Address - Country:US
Mailing Address - Phone:616-366-3780
Mailing Address - Fax:
Practice Address - Street 1:5304 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9708
Practice Address - Country:US
Practice Address - Phone:616-366-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015319103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling