Provider Demographics
NPI:1730853698
Name:WISEMAN, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
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 1:108 SUE LN
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9577
Mailing Address - Country:US
Mailing Address - Phone:973-216-5852
Mailing Address - Fax:
Practice Address - Street 1:200 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6444
Practice Address - Country:US
Practice Address - Phone:304-255-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00945701104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker