Provider Demographics
NPI:1588673156
Name:WISCH, ANDREW F (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:F
Last Name:WISCH
Suffix:
Gender:M
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:PO BOX 1104
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-1104
Mailing Address - Country:US
Mailing Address - Phone:207-594-2900
Mailing Address - Fax:
Practice Address - Street 1:120 TILLSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-3451
Practice Address - Country:US
Practice Address - Phone:207-594-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS963103TC1900X, 103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME047605OtherANTHEM BCBS
MM8215Medicare PIN