Provider Demographics
NPI:1689367526
Name:WIEDERRECHT, SAMANTHA (MS, PPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WIEDERRECHT
Suffix:
Gender:F
Credentials:MS, PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 ADOBE AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-3001
Mailing Address - Country:US
Mailing Address - Phone:307-351-2918
Mailing Address - Fax:
Practice Address - Street 1:1841 MADORA AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-3057
Practice Address - Country:US
Practice Address - Phone:307-358-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1386101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional