Provider Demographics
NPI:1902447006
Name:WIEDEMANN, CHRISTOPHER J
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:J
Last Name:WIEDEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 ROCKY WOOD CIR APT 125
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6580
Mailing Address - Country:US
Mailing Address - Phone:502-389-0580
Mailing Address - Fax:
Practice Address - Street 1:1780 ROCKY WOOD CIR APT 125
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-6580
Practice Address - Country:US
Practice Address - Phone:502-389-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst