Provider Demographics
NPI:1063638484
Name:NISSEN, STEPHANIE WISBY
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:WISBY
Last Name:NISSEN
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 1:7017 MCGOWAN CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243
Mailing Address - Country:US
Mailing Address - Phone:919-732-6214
Mailing Address - Fax:
Practice Address - Street 1:142 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:NC
Practice Address - Zip Code:27253-2808
Practice Address - Country:US
Practice Address - Phone:336-214-0709
Practice Address - Fax:336-931-9385
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5130101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional