Healthcare Provider Details

I. General information

NPI: 1558298521
Provider Name (Legal Business Name): CONSTANCE J WIEDMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 WAINWRIGHT AVE
BURLINGTON WI
53105-2269
US

IV. Provider business mailing address

1013 S 96TH ST
WEST ALLIS WI
53214-2608
US

V. Phone/Fax

Practice location:
  • Phone: 262-763-0210
  • Fax:
Mailing address:
  • Phone: 414-322-5083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: