MEDICARE: KELLY L WEIDEMAIER-KITSON MA

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	106H00000X	Marriage & Family Therapist	0929	NV

General Provider Information

NPI Number	:	1457505661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L WEIDEMAIER-KITSON MA

Provider Business Mailing Address
First Line	:	4080 BLUEWING WAY
Second Line	:
City	:	WASHOE VALLEY
State	:	NV
Zip	:	89704-9067
Country	:	US
Telephone Number	:	775-843-1100
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 W HUFFAKER LN
Second Line	:	#303
City	:	RENO
State	:	NV
Zip	:	89511-2346
Country	:	US
Telephone Number	:	775-843-1100
Fax Number	:

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

Provider Enumeration Date	:	11/14/2008
Last Update Date	:	11/14/2008

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