Provider Demographics
NPI:1962845891
Name:WIESE, HOLLY NOELLE (AM, MSW, LCSW)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:NOELLE
Last Name:WIESE
Suffix:
Gender:F
Credentials:AM, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 N CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2962
Mailing Address - Country:US
Mailing Address - Phone:847-431-7500
Mailing Address - Fax:
Practice Address - Street 1:2150 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3706
Practice Address - Country:US
Practice Address - Phone:312-942-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0161971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical