Provider Demographics
NPI:1154462455
Name:WISSORE, ROBERT P (LPC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:P
Last Name:WISSORE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ROUTE 1 BOX 28
Mailing Address - Street 2:
Mailing Address - City:MARQUAND
Mailing Address - State:MO
Mailing Address - Zip Code:63655
Mailing Address - Country:US
Mailing Address - Phone:573-866-2767
Mailing Address - Fax:573-472-2937
Practice Address - Street 1:102 S INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801
Practice Address - Country:US
Practice Address - Phone:573-472-3400
Practice Address - Fax:573-472-2937
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000577101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional