Provider Demographics
NPI:1306928973
Name:VIERA PSYCHOLOGICAL SERVICES PA
Entity type:Organization
Organization Name:VIERA PSYCHOLOGICAL SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESELER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:321-704-1135
Mailing Address - Street 1:345 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4301
Mailing Address - Country:US
Mailing Address - Phone:321-951-2100
Mailing Address - Fax:321-951-1204
Practice Address - Street 1:345 6TH AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4301
Practice Address - Country:US
Practice Address - Phone:321-951-2100
Practice Address - Fax:321-951-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7276103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9662Medicare ID - Type UnspecifiedMEDICARE GRP NUMBER