Healthcare Provider Details

I. General information

NPI: 1013924281
Provider Name (Legal Business Name): IRA EMANUEL WISOTZEK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD MENTAL HEALTH AND BEHAVIORAL SCIENCE
LYONS NJ
07939-5001
US

IV. Provider business mailing address

32 CRABAPPLE PL
NEWTOWN PA
18940-9281
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0180
  • Fax:
Mailing address:
  • Phone: 215-968-3906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35S100286300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0111941
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS015502
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: