Provider Demographics
NPI:1659652907
Name:WIESE, LAURA SMITH (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SMITH
Last Name:WIESE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 WADSWORTH BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-5233
Mailing Address - Country:US
Mailing Address - Phone:303-557-9747
Mailing Address - Fax:720-336-3043
Practice Address - Street 1:1692 WADSWORTH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-5233
Practice Address - Country:US
Practice Address - Phone:303-557-9747
Practice Address - Fax:720-336-3043
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC132371041C0700X
COCSW.099242761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical