Provider Demographics
NPI:1982716122
Name:WIESE-MOEN, GEORGIA MAY (MS LPC)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:MAY
Last Name:WIESE-MOEN
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:BILGER
Other - Middle Name:
Other - Last Name:SLEMPKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W MCMILLAN ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1031
Mailing Address - Country:US
Mailing Address - Phone:715-389-9382
Mailing Address - Fax:715-389-9381
Practice Address - Street 1:101 W. MCMILLAN STE 2B
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449
Practice Address - Country:US
Practice Address - Phone:715-389-9382
Practice Address - Fax:715-389-9381
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3046-125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43583900Medicaid