Provider Demographics
NPI:1245756816
Name:WIENS, MARTHA JANE M (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA JANE
Middle Name:M
Last Name:WIENS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1657 KANZA
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:KS
Mailing Address - Zip Code:67063-8100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 1/2 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:KS
Practice Address - Zip Code:67063-1525
Practice Address - Country:US
Practice Address - Phone:620-382-5302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2217104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS82-1971814Medicaid