Provider Demographics
NPI:1497973770
Name:WIEBE, KELLY LOUISE (MA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LOUISE
Last Name:WIEBE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 BIG LAKE CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6326
Mailing Address - Country:US
Mailing Address - Phone:573-449-4323
Mailing Address - Fax:
Practice Address - Street 1:2224 BIG LAKE CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6326
Practice Address - Country:US
Practice Address - Phone:573-449-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003025232101YP2500X
MO2002017783106H00000X
NC1288106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional