Provider Demographics
NPI:1528895026
Name:WIEGAND, MAKAYLA LYNN
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:LYNN
Last Name:WIEGAND
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 1:15913 W COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-9708
Mailing Address - Country:US
Mailing Address - Phone:920-221-5177
Mailing Address - Fax:
Practice Address - Street 1:629 RIVER ST STE C
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9189
Practice Address - Country:US
Practice Address - Phone:608-424-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1107-228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health