Provider Demographics
NPI:1790833069
Name:WISNESKI, CHARLES T (MSWLCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:WISNESKI
Suffix:
Gender:M
Credentials:MSWLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CASNER DR
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-3619
Mailing Address - Country:US
Mailing Address - Phone:928-634-0964
Mailing Address - Fax:928-649-6852
Practice Address - Street 1:703 S MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4615
Practice Address - Country:US
Practice Address - Phone:928-634-0964
Practice Address - Fax:928-649-6852
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-0714101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health