Provider Demographics
NPI:1871706507
Name:WIEDENHOEFT, JAMES D (LCSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:D
Last Name:WIEDENHOEFT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:262-345-5560
Mailing Address - Fax:262-345-5531
Practice Address - Street 1:1049 N LYNNDALE DR
Practice Address - Street 2:1B
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3050
Practice Address - Country:US
Practice Address - Phone:262-345-5599
Practice Address - Fax:262-345-5608
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2781-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2781-123OtherLCSW
WI39-1047224OtherTAX ID
WI39668500Medicaid