Provider Demographics
NPI:1326230566
Name:WIEMKEN, ALYCE A (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:ALYCE
Middle Name:A
Last Name:WIEMKEN
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 PARKVIEW CIR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7849
Mailing Address - Country:US
Mailing Address - Phone:701-298-9767
Mailing Address - Fax:
Practice Address - Street 1:2810 PARKVIEW CIR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7849
Practice Address - Country:US
Practice Address - Phone:701-298-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-12
Last Update Date:2007-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND496235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist