Healthcare Provider Details

I. General information

NPI: 1548873771
Provider Name (Legal Business Name): MICHAEL WIERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2020
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 NEWPORT CT
ISLAND LAKE IL
60042-9137
US

IV. Provider business mailing address

358 COLLEGE ST APT E
CRYSTAL LAKE IL
60014-6000
US

V. Phone/Fax

Practice location:
  • Phone: 847-526-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2419059
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: