Provider Demographics
NPI:1578076113
Name:WIESCH, JOHN C JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:WIESCH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 1ST ST
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-2410
Mailing Address - Country:US
Mailing Address - Phone:309-981-0364
Mailing Address - Fax:
Practice Address - Street 1:1844 1ST ST
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-2410
Practice Address - Country:US
Practice Address - Phone:309-981-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011783101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health