Provider Demographics
NPI:1043825375
Name:WIECEK, LINDA CAROL (COMS)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:CAROL
Last Name:WIECEK
Suffix:
Gender:F
Credentials:COMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2380
Mailing Address - Country:US
Mailing Address - Phone:716-888-4590
Mailing Address - Fax:
Practice Address - Street 1:1170 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-2380
Practice Address - Country:US
Practice Address - Phone:716-888-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22887225CX0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider