Provider Demographics
NPI:1952687337
Name:WISHART, RYAN (LMFT, LCAS)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:WISHART
Suffix:
Gender:M
Credentials:LMFT, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 CLEVELAND AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1616 CLEVELAND AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4855
Practice Address - Country:US
Practice Address - Phone:704-816-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2921101YA0400X
NC1492106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)