Healthcare Provider Details

I. General information

NPI: 1124733779
Provider Name (Legal Business Name): EMILY WIESSNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 NW CIVIC DR
GRESHAM OR
97030-5566
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

V. Phone/Fax

Practice location:
  • Phone: 971-292-1050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: