Healthcare Provider Details

I. General information

NPI: 1497637508
Provider Name (Legal Business Name): TIFFANY NOHELANI WIESNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 5TH AVE STE 109
NAPERVILLE IL
60563-3173
US

IV. Provider business mailing address

1895 RIDGEMONT CT
MONTGOMERY IL
60538-2932
US

V. Phone/Fax

Practice location:
  • Phone: 331-248-6194
  • Fax:
Mailing address:
  • Phone: 719-648-9945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: