Healthcare Provider Details

I. General information

NPI: 1497669626
Provider Name (Legal Business Name): CARMEN ALBERTA WISEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 LAKE EASTBROOK BLVD SE
GRAND RAPIDS MI
49546-5931
US

IV. Provider business mailing address

938 CANTERBURY ST SW
WYOMING MI
49509-2837
US

V. Phone/Fax

Practice location:
  • Phone: 616-604-8492
  • Fax: 616-604-8493
Mailing address:
  • Phone: 616-498-8640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: