Provider Demographics
NPI:1689895286
Name:WISDOM, PAULA JEAN (MSW)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JEAN
Last Name:WISDOM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11667 JINKERSON RD
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-3012
Mailing Address - Country:US
Mailing Address - Phone:573-436-4809
Mailing Address - Fax:
Practice Address - Street 1:11667 JINKERSON RD
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-3012
Practice Address - Country:US
Practice Address - Phone:573-436-4809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0030511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical