Provider Demographics
NPI:1275779472
Name:WIEGAND, MARIAN A (CTRS)
Entity Type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:A
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65936 HAVEN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MI
Mailing Address - Zip Code:48050-1779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65936 HAVEN RIDGE RD
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MI
Practice Address - Zip Code:48050-1779
Practice Address - Country:US
Practice Address - Phone:586-530-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI52865225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI52865OtherCERTIFIED THERAPEUTIC RECREATION SPECIALIST