Healthcare Provider Details

I. General information

NPI: 1861748964
Provider Name (Legal Business Name): DANIEL ELLIOT WYSOCKI LPE-I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W MORGAN ST STE 8
PARAGOULD AR
72450-3949
US

IV. Provider business mailing address

4852 GREGORY CV
JONESBORO AR
72401-7943
US

V. Phone/Fax

Practice location:
  • Phone: 870-335-9483
  • Fax: 870-933-9487
Mailing address:
  • Phone: 870-897-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number13-08EI
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: