Provider Demographics
NPI:1225366172
Name:WISEMAN, MARCIE C (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARCIE
Middle Name:C
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 N OAK ST
Mailing Address - Street 2:BUILDING B-3
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1744
Mailing Address - Country:US
Mailing Address - Phone:229-257-0100
Mailing Address - Fax:
Practice Address - Street 1:2704 N OAK ST
Practice Address - Street 2:BUILDING B-3
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1744
Practice Address - Country:US
Practice Address - Phone:229-257-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003561103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist