MEDICARE: MRS. KELLY LOUISE WIEBE 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	101YP2500X	Professional Counselor	2003025232	MO
2	106H00000X	Marriage & Family Therapist	2002017783	MO
3	106H00000X	Marriage & Family Therapist	1288	NC

General Provider Information

NPI Number	:	1497973770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY LOUISE WIEBE MA

Provider Business Mailing Address
First Line	:	2224 BIG LAKE CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-6326
Country	:	US
Telephone Number	:	573-449-4323
Fax Number	:

Provider Business Practice Location Address
First Line	:	2224 BIG LAKE CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-6326
Country	:	US
Telephone Number	:	573-449-4323
Fax Number	:

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	11/28/2018

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