Provider Demographics
NPI:1538117494
Name:WIEMERSLAGE, ELLA MAE (PSY D)
Entity Type:Individual
Prefix:DR
First Name:ELLA
Middle Name:MAE
Last Name:WIEMERSLAGE
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2437
Mailing Address - Country:US
Mailing Address - Phone:507-373-2384
Mailing Address - Fax:
Practice Address - Street 1:216 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2982
Practice Address - Country:US
Practice Address - Phone:507-373-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4288103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101668700Medicaid
680001462Medicare ID - Type Unspecified
MN680002925Medicare PIN
MN101668700Medicaid