Basic Information
Provider Information
NPI: 1003003583
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WISEMAN
FirstName: JUDITH
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential: LPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4225 W GLENDALE AVE
Address2: E119
City: PHOENIX
State: AZ
PostalCode: 85051
CountryCode: US
TelephoneNumber: 6239150270
FaxNumber:  
Practice Location
Address1: 4225 W GLENDALE AVE
Address2: E119
City: PHOENIX
State: AZ
PostalCode: 85051
CountryCode: US
TelephoneNumber: 6239150270
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/28/2007
LastUpdateDate: 09/28/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500XLPC-11882AZY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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