Provider Demographics
NPI:1932603081
Name:WISWELL, ADAM (PSYD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WISWELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3982 S. FIGUEROA STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037
Mailing Address - Country:US
Mailing Address - Phone:213-440-5824
Mailing Address - Fax:
Practice Address - Street 1:3982 S. FIGUEROA STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037
Practice Address - Country:US
Practice Address - Phone:213-440-5824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY28792103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist