Provider Demographics
NPI:1265679039
Name:WISOTSKY, WILLO (PHD)
Entity Type:Individual
Prefix:
First Name:WILLO
Middle Name:
Last Name:WISOTSKY
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 1:35 CROOKED HILL RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5415
Mailing Address - Country:US
Mailing Address - Phone:631-804-8830
Mailing Address - Fax:
Practice Address - Street 1:35 CROOKED HILL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5415
Practice Address - Country:US
Practice Address - Phone:631-804-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016173103TB0200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral