=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760388920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY CAROL WIETZKE SLPA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2026
-----------------------------------------------------
Last Update Date | 10/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4325 FORT APACHE RD. BUILDING 3
-----------------------------------------------------
City | WHITERIVER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-696-0104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1157
-----------------------------------------------------
City | FORT APACHE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85926-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-696-0104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | SLPA17703
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------