Healthcare Provider Details

I. General information

NPI: 1316776552
Provider Name (Legal Business Name): HEIDI L WIECHERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2024
Last Update Date: 07/27/2024
Certification Date: 07/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

2406 KELLING DR
MILLSTADT IL
62260-3029
US

V. Phone/Fax

Practice location:
  • Phone: 618-719-7230
  • Fax:
Mailing address:
  • Phone: 618-719-7230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number2011041815
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: