Provider Demographics
NPI:1528205374
Name:WIESNER, MICHELLE RENE (MA, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENE
Last Name:WIESNER
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3951 STORM CLOUD WAY
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7855
Mailing Address - Country:US
Mailing Address - Phone:303-963-5713
Mailing Address - Fax:
Practice Address - Street 1:3951 STORM CLOUD WAY
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7855
Practice Address - Country:US
Practice Address - Phone:303-963-5713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist