Provider Demographics
NPI:1407832546
Name:WISWELL, DENISE KAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:KAY
Last Name:WISWELL
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 1:901 HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3330
Mailing Address - Country:US
Mailing Address - Phone:989-317-3717
Mailing Address - Fax:
Practice Address - Street 1:301 S CRAPO ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2941
Practice Address - Country:US
Practice Address - Phone:989-772-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010180981041C0700X
MI6301010069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU006 107001882102OtherINTERMOUNTAIN HEALTH CARE
UTU003 942938348DEWOtherEDUCATORS MUTUAL
UTU002 898470OtherDESERET MUTUAL
UTU006 107001882102OtherINTERMOUNTAIN HEALTH CARE
TX003121016Medicare ID - Type UnspecifiedRCAR-RAILROAD MEDICARE
UTU002 898470OtherDESERET MUTUAL
TXS53050Medicare ID - Type UnspecifiedICAR - MEDICARE ADVANTAGE