Healthcare Provider Details

I. General information

NPI: 1336435122
Provider Name (Legal Business Name): LAURA MARIE WIECZOREK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 KIMBALL LN STE 305
LYNNFIELD MA
01940-2682
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 781-551-0999
  • Fax: 781-551-3396
Mailing address:
  • Phone: 781-551-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS017607
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number267729
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: