Provider Demographics
NPI:1659603652
Name:WIETLISBACH, SHIRLEY ESTER (MS/OTR)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:ESTER
Last Name:WIETLISBACH
Suffix:
Gender:F
Credentials:MS/OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 WYNFIELD CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-3144
Mailing Address - Country:US
Mailing Address - Phone:301-668-3501
Mailing Address - Fax:
Practice Address - Street 1:2301 RESEARCH BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3204
Practice Address - Country:US
Practice Address - Phone:301-424-5200
Practice Address - Fax:301-424-8063
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02147172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker