Provider Demographics
NPI:1932483229
Name:WISEMILLER, STACI JAN (LCAS-P)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:JAN
Last Name:WISEMILLER
Suffix:
Gender:F
Credentials:LCAS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 EXECUTIVE CIRCLE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:252-215-5700
Mailing Address - Fax:252-215-5701
Practice Address - Street 1:2313 EXECUTIVE CIR
Practice Address - Street 2:SUITE C
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3744
Practice Address - Country:US
Practice Address - Phone:252-215-5700
Practice Address - Fax:252-215-5701
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)