Provider Demographics
NPI:1720003262
Name:WASIELESKI, DAVID THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:THOMAS
Last Name:WASIELESKI
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 1:1002 SLATER ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-3937
Mailing Address - Country:US
Mailing Address - Phone:229-253-8400
Mailing Address - Fax:229-253-8485
Practice Address - Street 1:1002 SLATER ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-3937
Practice Address - Country:US
Practice Address - Phone:229-253-8400
Practice Address - Fax:229-253-8485
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2242103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist