Provider Demographics
NPI:1013213362
Name:WISECUP, JAMES J (DMIN)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:J
Last Name:WISECUP
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 W BANK LN
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1309
Mailing Address - Country:US
Mailing Address - Phone:203-602-9969
Mailing Address - Fax:203-602-2234
Practice Address - Street 1:53 W BANK LN
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1309
Practice Address - Country:US
Practice Address - Phone:203-602-9969
Practice Address - Fax:203-602-2234
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001142101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional