Provider Demographics
NPI:1861105819
Name:WIELAND, COLLEEN MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MICHELLE
Last Name:WIELAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MICHELLE
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19322 JESSE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-5072
Mailing Address - Country:US
Mailing Address - Phone:951-588-5527
Mailing Address - Fax:
Practice Address - Street 1:19322 JESSE LN STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-5072
Practice Address - Country:US
Practice Address - Phone:951-387-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA755281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical