Provider Demographics
NPI:1700381894
Name:WIEBE, KEMPTON MATHIAS
Entity Type:Individual
Prefix:
First Name:KEMPTON
Middle Name:MATHIAS
Last Name:WIEBE
Suffix:
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 1:901 MCDONOUGH ST APT 516
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2291
Mailing Address - Country:US
Mailing Address - Phone:757-561-1569
Mailing Address - Fax:
Practice Address - Street 1:3820 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-4831
Practice Address - Country:US
Practice Address - Phone:804-652-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool