Healthcare Provider Details

I. General information

NPI: 1477401446
Provider Name (Legal Business Name): HEIDI WISKUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 W EDGEWOOD DR STE 105
JEFFERSON CITY MO
65109-5886
US

IV. Provider business mailing address

514 BOXWOOD LN
JEFFERSON CITY MO
65109-6319
US

V. Phone/Fax

Practice location:
  • Phone: 573-260-1665
  • Fax:
Mailing address:
  • Phone: 641-216-3857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: