Healthcare Provider Details

I. General information

NPI: 1033421748
Provider Name (Legal Business Name): TRACY WIESE MFCT; MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2010
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 N MARTIN LUTHER KING BOULEVARD
N LAS VEGAS NV
89032
US

IV. Provider business mailing address

8936 SPANISH RIDGE AVE
LAS VEGAS NV
89148-1354
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-0909
  • Fax: 702-724-1978
Mailing address:
  • Phone: 702-998-2816
  • Fax: 702-998-2991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number01200
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: