Provider Demographics
NPI:1376847269
Name:WISEMAN, MARK WAYNE (LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 12TH AVE RD
Mailing Address - Street 2:NUMBER 144
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6300
Mailing Address - Country:US
Mailing Address - Phone:208-919-9706
Mailing Address - Fax:
Practice Address - Street 1:2422 12TH AVE RD
Practice Address - Street 2:NUMBER 144
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6300
Practice Address - Country:US
Practice Address - Phone:208-919-9706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3034101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health