Healthcare Provider Details

I. General information

NPI: 1528895026
Provider Name (Legal Business Name): MAKAYLA LYNN WIEGAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 RIVER ST STE C
BELLEVILLE WI
53508-9189
US

IV. Provider business mailing address

15913 W COUNTY ROAD C
EVANSVILLE WI
53536-9708
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-9100
  • Fax:
Mailing address:
  • Phone: 920-221-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1107-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: