Provider Demographics
NPI:1427734250
Name:WIEBUSCH, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:WIEBUSCH
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 1:1295 WATERS WAY
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55388-4507
Mailing Address - Country:US
Mailing Address - Phone:612-599-7681
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD STE 205
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-4551
Practice Address - Country:US
Practice Address - Phone:612-446-3921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN177141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical