MEDICARE: KATELYN RICHELLE WIERENGA LCSW

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	1041C0700X	Clinical Social Worker	LCSW-22214	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LMSW-19606	OTHER	AZ	STATE OF ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS

General Provider Information

NPI Number	:	1255007217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN RICHELLE WIERENGA LCSW

Provider Business Mailing Address
First Line	:	2531 S 73RD DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-1588
Country	:	US
Telephone Number	:	602-561-4984
Fax Number	:

Provider Business Practice Location Address
First Line	:	2531 S 73RD DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-1588
Country	:	US
Telephone Number	:	602-561-4984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2021
Last Update Date	:	04/29/2024

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