Healthcare Provider Details

I. General information

NPI: 1154462455
Provider Name (Legal Business Name): ROBERT P. WISSORE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S INTERSTATE DR
SIKESTON MO
63801
US

IV. Provider business mailing address

ROUTE 1 BOX 28
MARQUAND MO
63655
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-3400
  • Fax: 573-472-2937
Mailing address:
  • Phone: 573-866-2767
  • Fax: 573-472-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000577
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: