Provider Demographics
NPI:1992696025
Name:WIETHOFF, LAURE (EDS)
Entity type:Individual
Prefix:MS
First Name:LAURE
Middle Name:
Last Name:WIETHOFF
Suffix:
Gender:X
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6192 CHATSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:WHITESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46075-4484
Mailing Address - Country:US
Mailing Address - Phone:630-956-3722
Mailing Address - Fax:
Practice Address - Street 1:815 N STATE ROAD 29
Practice Address - Street 2:
Practice Address - City:MICHIGANTOWN
Practice Address - State:IN
Practice Address - Zip Code:46057-9616
Practice Address - Country:US
Practice Address - Phone:765-249-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10183770103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool