Provider Demographics
NPI:1144567579
Name:WYSE, DONNA MARIE (LSW, LPC)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:WYSE
Suffix:
Gender:F
Credentials:LSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22251 STATE ROUTE 2
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-9452
Mailing Address - Country:US
Mailing Address - Phone:419-445-1552
Mailing Address - Fax:419-445-1401
Practice Address - Street 1:22251 STATE ROUTE 2
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-9452
Practice Address - Country:US
Practice Address - Phone:419-445-1552
Practice Address - Fax:419-445-1401
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1100131101Y00000X
OHS0600429104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker