Individual
MR. STEVEN ROGER WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
L.P.
Contact information
Practice address
2780 SNELLING AVE N STE 104, ROSEVILLE, MN 55113-7115
(651) 633-5290
(651) 633-5238
Mailing address
21211 IMPERIAL AVE N, FOREST LAKE, MN 55025-9547
(651) 464-1121
(651) 633-5238
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
LP1426
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
04Q65WI
BCBSM NON PAR PROVIDER ID
MN
Enumeration date
04/17/2007
Last updated
07/08/2007
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