Provider Demographics
NPI:1912570300
Name:WISNIEWSKI, CLARISSA GRACE (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:GRACE
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:GRACE
Other - Last Name:DINGUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CF-SLP
Mailing Address - Street 1:11724 NEGLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1441
Mailing Address - Country:US
Mailing Address - Phone:314-630-8466
Mailing Address - Fax:
Practice Address - Street 1:8840 N MAGNOLIA AVE STE 220
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4516
Practice Address - Country:US
Practice Address - Phone:619-749-7059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist