Provider Demographics
NPI:1245958727
Name:WIECK, CYLIE
Entity type:Individual
Prefix:
First Name:CYLIE
Middle Name:
Last Name:WIECK
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 1:1410 COLUMBIA RD APT 10F
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4018
Mailing Address - Country:US
Mailing Address - Phone:402-708-7825
Mailing Address - Fax:
Practice Address - Street 1:1410 COLUMBIA RD APT 10F
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4018
Practice Address - Country:US
Practice Address - Phone:402-708-7825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL178.019564101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program