Provider Demographics
NPI:1093749624
Name:WISNIEWSKI, MICHAEL GERARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GERARD
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29425 CHAGRIN BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4639
Mailing Address - Country:US
Mailing Address - Phone:216-292-0610
Mailing Address - Fax:216-292-0627
Practice Address - Street 1:29425 CHAGRIN BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4639
Practice Address - Country:US
Practice Address - Phone:216-292-0610
Practice Address - Fax:216-292-0627
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3607103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0692175Medicaid
OH0692175Medicaid