MEDICARE: MRS. HOLLIS WIESE LMFT

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	119508	CA

General Provider Information

NPI Number	:	1487272621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HOLLIS WIESE LMFT

Provider Business Mailing Address
First Line	:	4024 LOS FELIZ BLVD APT 2
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-2366
Country	:	US
Telephone Number	:	949-338-2429
Fax Number	:

Provider Business Practice Location Address
First Line	:	4024 LOS FELIZ BLVD APT 2
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-2366
Country	:	US
Telephone Number	:	949-338-2429
Fax Number	:

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

Provider Enumeration Date	:	07/13/2020
Last Update Date	:	07/13/2020

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