Provider Demographics
NPI:1275754418
Name:WISS, MARTIN BARRY (LICSW, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:BARRY
Last Name:WISS
Suffix:
Gender:M
Credentials:LICSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55328-8822
Mailing Address - Country:US
Mailing Address - Phone:763-482-1243
Mailing Address - Fax:
Practice Address - Street 1:300 2ND ST S
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-8822
Practice Address - Country:US
Practice Address - Phone:763-482-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN72221041C0700X
MN653106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist