Provider Demographics
NPI:1528445715
Name:WIEMER, KAREN ELLEN X (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:ELLEN
Last Name:WIEMER
Suffix:X
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N FARRELL RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-2364
Mailing Address - Country:US
Mailing Address - Phone:815-838-4959
Mailing Address - Fax:
Practice Address - Street 1:16622 W 159TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8014
Practice Address - Country:US
Practice Address - Phone:815-838-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.002908225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist