Provider Demographics
NPI:1073159539
Name:WISEMAN, JUSTIN M (PSYD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 19TH ST APT 1405
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-1791
Mailing Address - Country:US
Mailing Address - Phone:314-255-9594
Mailing Address - Fax:
Practice Address - Street 1:401 E 19TH ST APT 1405
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-1791
Practice Address - Country:US
Practice Address - Phone:314-255-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018037238103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical