Healthcare Provider Details

I. General information

NPI: 1700264892
Provider Name (Legal Business Name): MARK WEILAGE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3308 SAMSON WAY SUITE 101
BELLEVUE NE
68123-3234
US

IV. Provider business mailing address

7261 MERCY RD
OMAHA NE
68124-2311
US

V. Phone/Fax

Practice location:
  • Phone: 402-827-1577
  • Fax: 402-898-3134
Mailing address:
  • Phone: 402-398-6248
  • Fax: 402-829-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number479
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: