Healthcare Provider Details

I. General information

NPI: 1285923870
Provider Name (Legal Business Name): MRS. MICHELLE WISNESKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE KLASSEN

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 E 1ST AVE SUITE 5
APPLETON WI
54911-1586
US

IV. Provider business mailing address

1068 SANDPOINT RDG
NEENAH WI
54956-5639
US

V. Phone/Fax

Practice location:
  • Phone: 920-257-4601
  • Fax:
Mailing address:
  • Phone: 920-574-5946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number127-3605381
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: