Provider Demographics
NPI:1205306321
Name:WISEMAN, BAILEY (LPC)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK PL STE 11
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1883
Mailing Address - Country:US
Mailing Address - Phone:614-806-0495
Mailing Address - Fax:
Practice Address - Street 1:201 PARK PL STE 11
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1883
Practice Address - Country:US
Practice Address - Phone:614-806-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-01
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013901101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL81-4957995OtherTAX ID