Provider Demographics
NPI:1841919701
Name:WIEGAND, SAMANTHA NICOLE (EDS, MS)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:EDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4826 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-3068
Mailing Address - Country:US
Mailing Address - Phone:618-540-4135
Mailing Address - Fax:
Practice Address - Street 1:707 N SMILEY ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1353
Practice Address - Country:US
Practice Address - Phone:618-632-6391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2379352103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool