Basic Information
Provider Information | |||||||||
NPI: | 1093818379 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WIERSMA | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 216 E LUVERNE ST | ||||||||
Address2: | PO BOX 686 | ||||||||
City: | LUVERNE | ||||||||
State: | MN | ||||||||
PostalCode: | 561561610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5072839511 | ||||||||
FaxNumber: | 5072839514 | ||||||||
Practice Location | |||||||||
Address1: | 1016 8TH AVENUE SW | ||||||||
Address2: |   | ||||||||
City: | PIPESTONE | ||||||||
State: | MN | ||||||||
PostalCode: | 56164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5078255888 | ||||||||
FaxNumber: | 5078255880 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 16660 | MN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.