Provider Demographics
NPI:1275675142
Name:WISEMAN, NANCY L (LCSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:LCSW
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 69
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63302-0069
Mailing Address - Country:US
Mailing Address - Phone:636-949-6605
Mailing Address - Fax:636-949-6607
Practice Address - Street 1:316 S 2ND ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-3402
Practice Address - Country:US
Practice Address - Phone:636-949-6605
Practice Address - Fax:636-949-6607
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0053431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical