Healthcare Provider Details

I. General information

NPI: 1821398108
Provider Name (Legal Business Name): JUDY KAYE WIEBERG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 CAPURRO WAY SUITE 105
SPARKS NV
89431-8518
US

IV. Provider business mailing address

11040 HEARTPINE ST
RENO NV
89506-8952
US

V. Phone/Fax

Practice location:
  • Phone: 775-848-7674
  • Fax:
Mailing address:
  • Phone: 775-848-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCPOO21
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1089-L
License Number StateNV

VIII. Authorized Official

Name: JUDY KAYE WIEBERG
Title or Position: COUNSELOR
Credential: LCPC
Phone: 775-848-7674