Provider Demographics
NPI:1265410286
Name:WIESNER, DAVID CHARLES
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHARLES
Last Name:WIESNER
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 1:8290 165TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3948
Mailing Address - Country:US
Mailing Address - Phone:425-869-2644
Mailing Address - Fax:425-867-0930
Practice Address - Street 1:2610 WYCLIFF RD
Practice Address - Street 2:SUITE 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3073
Practice Address - Country:US
Practice Address - Phone:919-782-4060
Practice Address - Fax:919-782-0906
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60405036103T00000X
NC2039103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04080OtherBC/BS PROVIDER NUMBER