Provider Demographics
NPI:1780036608
Name:WISEMAN, BRANDY (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 N BROWN RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8198
Mailing Address - Country:US
Mailing Address - Phone:678-365-3695
Mailing Address - Fax:
Practice Address - Street 1:1755 N BROWN RD STE 120
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8198
Practice Address - Country:US
Practice Address - Phone:678-365-3695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-02
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010593101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional