Basic Information
| Provider Information | |||||||||
| NPI: | 1083002091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIANDT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3445 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443193028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306444095 | ||||||||
| FaxNumber: | 3306452033 | ||||||||
| Practice Location | |||||||||
| Address1: | 3445 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443193028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306444095 | ||||||||
| FaxNumber: | 3306452033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2014 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S. 0012823 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0294091 | 05 | OH | MEDICAID |