Provider Demographics
NPI:1336646298
Name:WEISE, LORETA
Entity Type:Individual
Prefix:
First Name:LORETA
Middle Name:
Last Name:WEISE
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 1:3228 TENBROECK AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5011
Mailing Address - Country:US
Mailing Address - Phone:347-641-0864
Mailing Address - Fax:
Practice Address - Street 1:15813 72ND AVE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1140
Practice Address - Country:US
Practice Address - Phone:718-380-7600
Practice Address - Fax:718-380-6675
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2018-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency