Provider Demographics
NPI:1922420579
Name:REGINA KATHERINE WISENBAKER
Entity Type:Organization
Organization Name:REGINA KATHERINE WISENBAKER
Other - Org Name:WISENBAKER COUNSELING SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:WISENBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:229-630-6587
Mailing Address - Street 1:415 COWART AVE STE B
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2651
Mailing Address - Country:US
Mailing Address - Phone:229-630-6587
Mailing Address - Fax:
Practice Address - Street 1:415 COWART AVE STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2651
Practice Address - Country:US
Practice Address - Phone:229-630-6587
Practice Address - Fax:229-257-0757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW005046172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty