Provider Demographics
NPI:1518785781
Name:WISEMAN, TAMARA MARSHELL
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:MARSHELL
Last Name:WISEMAN
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 1:180 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-5401
Mailing Address - Country:US
Mailing Address - Phone:304-872-0058
Mailing Address - Fax:304-872-0116
Practice Address - Street 1:180 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-5401
Practice Address - Country:US
Practice Address - Phone:304-872-0058
Practice Address - Fax:304-872-0116
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician