Provider Demographics
NPI:1609652320
Name:WIEBELT, MADISON NICHOLE
Entity Type:Individual
Prefix:MS
First Name:MADISON
Middle Name:NICHOLE
Last Name:WIEBELT
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 1:35614 LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-5840
Mailing Address - Country:US
Mailing Address - Phone:985-641-1901
Mailing Address - Fax:
Practice Address - Street 1:35614 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-5840
Practice Address - Country:US
Practice Address - Phone:985-641-1901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA94472355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant