Provider Demographics
NPI:1821449455
Name:WISNESS, MONIQUE MACHELLE (LSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MACHELLE
Last Name:WISNESS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 4TH AVE SE APT 116
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-7732
Mailing Address - Country:US
Mailing Address - Phone:701-566-9020
Mailing Address - Fax:
Practice Address - Street 1:1008 4TH AVE SE APT 116
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7732
Practice Address - Country:US
Practice Address - Phone:701-566-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3648104100000X
ND45600224171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1460241Medicaid