MEDICARE: STEPHANIE WIESE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	180007986	IL

General Provider Information

NPI Number	:	1114281870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEPHANIE WIESE

Provider Business Mailing Address
First Line	:	161 SPRINGBROOK TRL S
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-4016
Country	:	US
Telephone Number	:	630-818-7899
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 W WASHINGTON ST
Second Line	:	SUITE 340
City	:	OSWEGO
State	:	IL
Zip	:	60543-8214
Country	:	US
Telephone Number	:	630-818-7899
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. STEPHANIE WIESE
Credential	:	LCPC
Telephone Number	:	630-818-7899

Provider Enumeration Date	:	06/27/2012
Last Update Date	:	06/27/2012

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