Healthcare Provider Details

I. General information

NPI: 1912286808
Provider Name (Legal Business Name): LADONA RAE WIEBLER M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 E ARMSTRONG AVE
PEORIA IL
61603-3201
US

IV. Provider business mailing address

507 E ARMSTRONG AVE
PEORIA IL
61603-3201
US

V. Phone/Fax

Practice location:
  • Phone: 309-686-1177
  • Fax: 309-686-7722
Mailing address:
  • Phone: 309-686-1177
  • Fax: 309-686-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146001359
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1052473
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: