Provider Demographics
NPI:1043825151
Name:WIEMKEN, AMANDA MARIE DIVITA (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MARIE DIVITA
Last Name:WIEMKEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 SOLOMONS ISLAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3730
Mailing Address - Country:US
Mailing Address - Phone:410-757-2077
Mailing Address - Fax:
Practice Address - Street 1:2431 SOLOMONS ISLAND RD STE 200
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3730
Practice Address - Country:US
Practice Address - Phone:410-757-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06456103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist