Provider Demographics
NPI:1104083153
Name:WIENER, ROBERTA GENE (MLS)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:GENE
Last Name:WIENER
Suffix:
Gender:F
Credentials:MLS
Other - Prefix:MS
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:GENET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1426 CHEYENNE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3009
Mailing Address - Country:US
Mailing Address - Phone:719-471-2587
Mailing Address - Fax:
Practice Address - Street 1:1426 CHEYENNE BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3009
Practice Address - Country:US
Practice Address - Phone:719-471-2587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO130183172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist