Provider Demographics
NPI:1730558214
Name:WISEMAN, ROBERT (PPC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1414
Mailing Address - Country:US
Mailing Address - Phone:304-927-5262
Mailing Address - Fax:304-927-0378
Practice Address - Street 1:141 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1414
Practice Address - Country:US
Practice Address - Phone:304-927-5262
Practice Address - Fax:304-927-0378
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV278101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor