Provider Demographics
NPI:1588736128
Name:JEFF D WIESE LCSW PLLC
Entity type:Organization
Organization Name:JEFF D WIESE LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:D
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:520-742-9166
Mailing Address - Street 1:5425 N ORACLE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3890
Mailing Address - Country:US
Mailing Address - Phone:520-742-9166
Mailing Address - Fax:520-742-9146
Practice Address - Street 1:5425 N ORACLE RD STE 115
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3890
Practice Address - Country:US
Practice Address - Phone:520-742-9166
Practice Address - Fax:520-742-9146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW0712101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW0712OtherLICENSE