Provider Demographics
NPI:1619370491
Name:WIETEN, VALERIE
Entity type:Individual
Prefix:MRS
First Name:VALERIE
Middle Name:
Last Name:WIETEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 BROWNWOOD AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3651
Mailing Address - Country:US
Mailing Address - Phone:616-822-9051
Mailing Address - Fax:616-559-1056
Practice Address - Street 1:2505 ARDMORE ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4924
Practice Address - Country:US
Practice Address - Phone:616-822-9051
Practice Address - Fax:616-559-1056
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL529610235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist