Provider Demographics
NPI:1275547903
Name:WIETZKE, MARY LYNN (CCCSLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYNN
Last Name:WIETZKE
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5500 ARMSTRONG ROAD-114 PR
Mailing Address - Street 2:VA MEDICAL CENTER
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-1099
Mailing Address - Country:US
Mailing Address - Phone:269-966-5600
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG ROAD-114 PR
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-1099
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01073833235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist