Healthcare Provider Details

I. General information

NPI: 1558194167
Provider Name (Legal Business Name): TRISTA WYSONG LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 N MAIN ST
WICHITA KS
67203-3608
US

IV. Provider business mailing address

702 W CHERRY ST
HILL CITY KS
67642-1732
US

V. Phone/Fax

Practice location:
  • Phone: 316-263-8807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number01895
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: