=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437489176
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL ANN WIETSCHNER M.S. CCC/SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2009
-----------------------------------------------------
Last Update Date | 01/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 HOWARD AVE
-----------------------------------------------------
City | WOODMERE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11598-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-791-5252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 375 HOWARD AVE
-----------------------------------------------------
City | WOODMERE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11598-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-467-6274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 008737
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 008737
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------