Provider Demographics
NPI:1861748964
Name:WYSOCKI, DANIEL ELLIOT (LPE-I)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ELLIOT
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:LPE-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4852 GREGORY CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7943
Mailing Address - Country:US
Mailing Address - Phone:870-897-0977
Mailing Address - Fax:
Practice Address - Street 1:1101 W MORGAN ST STE 8
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-3949
Practice Address - Country:US
Practice Address - Phone:870-335-9483
Practice Address - Fax:870-933-9487
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR13-08EI103T00000X
AR12-26 AE-PL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional