Provider Demographics
NPI:1164686242
Name:WISEMON, GILA (CASAC-T)
Entity Type:Individual
Prefix:
First Name:GILA
Middle Name:
Last Name:WISEMON
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31094
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-1094
Mailing Address - Country:US
Mailing Address - Phone:518-952-8140
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:3619 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4203
Practice Address - Country:US
Practice Address - Phone:718-998-7500
Practice Address - Fax:718-998-7955
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18895101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420795Medicaid