Provider Demographics
NPI:1467876300
Name:WISARD, CARLA (MA)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:
Last Name:WISARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 MARLANE DR
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9224
Mailing Address - Country:US
Mailing Address - Phone:614-801-3024
Mailing Address - Fax:
Practice Address - Street 1:3805 MARLANE DR
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9224
Practice Address - Country:US
Practice Address - Phone:614-801-3024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOS1-05-1135 JJT7033103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool