Provider Demographics
NPI:1275124125
Name:WICHTNER, BETIANN KATHRINE
Entity Type:Individual
Prefix:MRS
First Name:BETIANN
Middle Name:KATHRINE
Last Name:WICHTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8586 28 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48094-1502
Mailing Address - Country:US
Mailing Address - Phone:586-243-2669
Mailing Address - Fax:
Practice Address - Street 1:8586 28 MILE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48094-1502
Practice Address - Country:US
Practice Address - Phone:586-243-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF500086086253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI45617887Medicaid