Healthcare Provider Details

I. General information

NPI: 1831162486
Provider Name (Legal Business Name): PETER L WIETHE MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 W MORRIS ST
INDIANAPOLIS IN
46221-1629
US

IV. Provider business mailing address

3403 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

V. Phone/Fax

Practice location:
  • Phone: 317-957-2500
  • Fax:
Mailing address:
  • Phone: 317-957-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number39001550A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001550A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: