Provider Demographics
NPI:1245589860
Name:WISEMAN GROUP
Entity Type:Organization
Organization Name:WISEMAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:208-919-9706
Mailing Address - Street 1:2422 12TH AVE RD
Mailing Address - Street 2:144
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6300
Mailing Address - Country:US
Mailing Address - Phone:208-919-9706
Mailing Address - Fax:
Practice Address - Street 1:2422 12TH AVE RD
Practice Address - Street 2:144
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6300
Practice Address - Country:US
Practice Address - Phone:208-919-9706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3034251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management