Provider Demographics
NPI:1396831202
Name:WIETERS, JOANNE BRADLEY (MSW)
Entity Type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:BRADLEY
Last Name:WIETERS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 EXECUTIVE CTR BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902
Mailing Address - Country:US
Mailing Address - Phone:915-545-1242
Mailing Address - Fax:915-545-1243
Practice Address - Street 1:444 EXECUTIVE CTR BLVD
Practice Address - Street 2:STE 230
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-545-1242
Practice Address - Fax:915-545-1243
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07971041C0700X
NMI02191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI0219OtherLCSW LICENSE
TX0797OtherLCSW LICENSE
S74AMedicare ID - Type Unspecified