Provider Demographics
NPI:1962015628
Name:WIEST, GRAHAMM (PSYD)
Entity type:Individual
Prefix:DR
First Name:GRAHAMM
Middle Name:
Last Name:WIEST
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N EUCLID ST STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5514
Mailing Address - Country:US
Mailing Address - Phone:714-871-5646
Mailing Address - Fax:
Practice Address - Street 1:1110 E CHAPMAN AVE STE 202
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2139
Practice Address - Country:US
Practice Address - Phone:714-744-9754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
CA34353103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist