Provider Demographics
NPI:1558819748
Name:WEISE, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
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:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:YORK HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:03911-0236
Mailing Address - Country:US
Mailing Address - Phone:207-475-7798
Mailing Address - Fax:
Practice Address - Street 1:62 PORTLAND RD STE 42
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6650
Practice Address - Country:US
Practice Address - Phone:207-475-7798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC149461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical