Healthcare Provider Details

I. General information

NPI: 1033034749
Provider Name (Legal Business Name): TYANN WIEDERHOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE MISSOURI RD
LEES SUMMIT MO
64086-4722
US

IV. Provider business mailing address

1200 SE 12TH TER
LEES SUMMIT MO
64081-2170
US

V. Phone/Fax

Practice location:
  • Phone: 636-579-0906
  • Fax:
Mailing address:
  • Phone: 636-579-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2026034217
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: