Healthcare Provider Details

I. General information

NPI: 1336936236
Provider Name (Legal Business Name): DEBORAH J WIEZOREK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5436 ENTERPRISE DR
LINCOLN NE
68521-1063
US

IV. Provider business mailing address

5436 ENTERPRISE DR
LINCOLN NE
68521-1063
US

V. Phone/Fax

Practice location:
  • Phone: 402-515-7449
  • Fax:
Mailing address:
  • Phone: 402-515-7449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: