Healthcare Provider Details

I. General information

NPI: 1508117961
Provider Name (Legal Business Name): JOHN W WUELLENWEBER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 FIELDSTONE RD
HOPKINTON NH
03229-2676
US

IV. Provider business mailing address

102 FIELDSTONE RD
HOPKINTON NH
03229-2676
US

V. Phone/Fax

Practice location:
  • Phone: 603-568-1115
  • Fax:
Mailing address:
  • Phone: 603-568-1115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1243
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: