MEDICARE: TERESA GRACE-WIEBER

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1447641444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA GRACE-WIEBER

Provider Business Mailing Address
First Line	:	167 BEACH 3RD ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-5603
Country	:	US
Telephone Number	:	516-413-2838
Fax Number	:

Provider Business Practice Location Address
First Line	:	167 BEACH 3RD ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-5603
Country	:	US
Telephone Number	:	516-413-2838
Fax Number	:

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

Provider Enumeration Date	:	02/11/2015
Last Update Date	:	02/11/2015

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Directions to “ TERESA GRACE-WIEBER ” Practice Location

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