Healthcare Provider Details

I. General information

NPI: 1154095255
Provider Name (Legal Business Name): LISA WIETHE MSCJ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PARK VIEW LN
WHEELING WV
26003-5493
US

IV. Provider business mailing address

14 E GRAFTON RD STE C
FAIRMONT WV
26554-4465
US

V. Phone/Fax

Practice location:
  • Phone: 304-243-1865
  • Fax:
Mailing address:
  • Phone: 304-559-3370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: