Healthcare Provider Details

I. General information

NPI: 1659967412
Provider Name (Legal Business Name): MISTY M WISENBERGER CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 TOWNSHIP ROAD 365
SOUTH POINT OH
45680-9409
US

IV. Provider business mailing address

49 TOWNSHIP ROAD 365
SOUTH POINT OH
45680-9409
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-0221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: