Provider Demographics
NPI:1962540823
Name:WIEDLEBACHER, LAURA MICHELLE (MA, PCC-S, LICDC-CS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MICHELLE
Last Name:WIEDLEBACHER
Suffix:
Gender:F
Credentials:MA, PCC-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 S MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-3967
Mailing Address - Country:US
Mailing Address - Phone:740-375-9091
Mailing Address - Fax:740-369-5931
Practice Address - Street 1:196 S MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-3967
Practice Address - Country:US
Practice Address - Phone:740-375-9091
Practice Address - Fax:740-369-5931
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional