Healthcare Provider Details

I. General information

NPI: 1699803783
Provider Name (Legal Business Name): DEANNA JO WIESE M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13520 ASHBURY DR
CARMEL IN
46032-8225
US

IV. Provider business mailing address

3520 WILD IVY DR
INDIANAPOLIS IN
46227-9731
US

V. Phone/Fax

Practice location:
  • Phone: 800-900-6304
  • Fax: 317-846-9484
Mailing address:
  • Phone: 317-633-9115
  • Fax: 317-889-3150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22002134A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: