Basic Information
| Provider Information | |||||||||
| NPI: | 1205072931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIESNER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5677 OBERLIN DR STE 106 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584578419 | ||||||||
| FaxNumber: | 8584570670 | ||||||||
| Practice Location | |||||||||
| Address1: | 5677 OBERLIN DR STE 106 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584578419 | ||||||||
| FaxNumber: | 8584570670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 5996 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.