Provider Demographics
NPI:1144598715
Name:WISELEY, MICHAEL RALPH (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RALPH
Last Name:WISELEY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:RALPH
Other - Last Name:WISELEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:1776 S PALO VERDE AVE APT B103
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-2308
Mailing Address - Country:US
Mailing Address - Phone:520-323-5677
Mailing Address - Fax:
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-130211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical