Provider Demographics
NPI:1144510470
Name:WEICHERT, VIRGINIA VICTORIA (TLLP)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:VICTORIA
Last Name:WEICHERT
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37300 MILLSTONE TRL
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MI
Mailing Address - Zip Code:48048-3131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37300 MILLSTONE TRL
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MI
Practice Address - Zip Code:48048-3131
Practice Address - Country:US
Practice Address - Phone:586-817-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5005OtherMACOME COUNTY COMMUNITY MENTAL HEALTH
MI750910402OtherBCBS FEDERAL
MI750910402OtherBCBS MICHIGAN
MI750910402OtherBCBS CHRYSLER
MI750910402OtherBCBS OUT OF STATE
MIXX19153OtherHEALTHPLUS
MI032919Medicaid
MI750910402OtherBLUE CROSS TRUST