Provider Demographics
NPI:1366958019
Name:WIEDER, CRAIG ANDREW (LSW)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:ANDREW
Last Name:WIEDER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GATEWAY DR APT 412A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-5940
Mailing Address - Country:US
Mailing Address - Phone:215-704-8383
Mailing Address - Fax:
Practice Address - Street 1:3600 GATEWAY DR APT 412A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-5940
Practice Address - Country:US
Practice Address - Phone:215-704-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0244841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical