Provider Demographics
NPI:1639535818
Name:WISDOM, RICHELLE
Entity Type:Individual
Prefix:
First Name:RICHELLE
Middle Name:
Last Name:WISDOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E ROLLA RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-2658
Mailing Address - Country:US
Mailing Address - Phone:573-259-7392
Mailing Address - Fax:
Practice Address - Street 1:119 N BENTON ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2501
Practice Address - Country:US
Practice Address - Phone:573-433-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor