Provider Demographics
NPI:1912630278
Name:WIECHMAN, KELLY MAURINE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MAURINE
Last Name:WIECHMAN
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 1:3320 PETERSON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-1739
Mailing Address - Country:US
Mailing Address - Phone:785-371-1414
Mailing Address - Fax:785-371-4519
Practice Address - Street 1:3320 PETERSON RD STE 104
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-1739
Practice Address - Country:US
Practice Address - Phone:785-371-1414
Practice Address - Fax:785-371-4519
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2980103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist