Provider Demographics
NPI:1497737902
Name:WIELAND, KEVIN L (PSYD, HSPP)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:WIELAND
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1415 MAGNAVOX WAY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1565
Mailing Address - Country:US
Mailing Address - Phone:260-483-7207
Mailing Address - Fax:260-483-0836
Practice Address - Street 1:1415 MAGNAVOX WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1565
Practice Address - Country:US
Practice Address - Phone:260-483-7207
Practice Address - Fax:260-483-0836
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN20041419A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200360310AMedicaid
IN200360310AMedicaid