Provider Demographics
NPI:1275566325
Name:WISH, CAROL W (PH D)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:W
Last Name:WISH
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6091 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-8921
Mailing Address - Country:US
Mailing Address - Phone:608-846-5093
Mailing Address - Fax:
Practice Address - Street 1:2727 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2255
Practice Address - Country:US
Practice Address - Phone:608-238-9354
Practice Address - Fax:608-238-7675
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI920103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39046100Medicaid
WI88396Medicare ID - Type Unspecified
WI39046100Medicaid