Provider Demographics
NPI:1306948211
Name:WIENER, LANCE DAVID (MA CCC SLP)
Entity type:Individual
Prefix:MR
First Name:LANCE
Middle Name:DAVID
Last Name:WIENER
Suffix:
Gender:M
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20281 E COUNTRY CLUB DR
Mailing Address - Street 2:APT 2504
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3010
Mailing Address - Country:US
Mailing Address - Phone:305-937-4972
Mailing Address - Fax:
Practice Address - Street 1:2785 NE 183RD ST
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-2171
Practice Address - Country:US
Practice Address - Phone:305-932-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA510174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890177500Medicaid