Provider Demographics
NPI:1699803783
Name:WIESE, DEANNA JO (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:JO
Last Name:WIESE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 WILD IVY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-9731
Mailing Address - Country:US
Mailing Address - Phone:317-633-9115
Mailing Address - Fax:317-889-3150
Practice Address - Street 1:13520 ASHBURY DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8225
Practice Address - Country:US
Practice Address - Phone:800-900-6304
Practice Address - Fax:317-846-9484
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002134A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist