Basic Information
| Provider Information | |||||||||
| NPI: | 1477630911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIENER | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 W NC HIGHWAY 54 | ||||||||
| Address2: | STE 103 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277075572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193540840 | ||||||||
| FaxNumber: | 9197484441 | ||||||||
| Practice Location | |||||||||
| Address1: | 6885 CLIFFDALE RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283142834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103390400 | ||||||||
| FaxNumber: | 9103390396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 12/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3027 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6000810 | 05 | NC | MEDICAID | 046NC | 01 | NY | BCBS PIN | OTHER |