Healthcare Provider Details

I. General information

NPI: 1245164151
Provider Name (Legal Business Name): SHANICE WIECHMAN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 HOLDEN BLVD
FAIRFIELD OH
45014-2109
US

IV. Provider business mailing address

5405 PHILLORET DR
CINCINNATI OH
45239-7630
US

V. Phone/Fax

Practice location:
  • Phone: 513-858-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.01720
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: