Provider Demographics
NPI:1639550874
Name:WISHART, ALFRED BERNARD (LPC, LCDC, MAC, CRC)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:BERNARD
Last Name:WISHART
Suffix:
Gender:M
Credentials:LPC, LCDC, MAC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5507 REIGER AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-5041
Mailing Address - Country:US
Mailing Address - Phone:214-923-5093
Mailing Address - Fax:
Practice Address - Street 1:5507 REIGER AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-5041
Practice Address - Country:US
Practice Address - Phone:214-923-5093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12537101YA0400X
TX71266101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health