Healthcare Provider Details

I. General information

NPI: 1497519979
Provider Name (Legal Business Name): PRISMA WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 WATERTOWN PLANK RD STE 102
ELM GROVE WI
53122-2222
US

IV. Provider business mailing address

2031 RIDGE END RD
VIRGINIA BEACH VA
23454-1028
US

V. Phone/Fax

Practice location:
  • Phone: 206-785-1015
  • Fax: 206-785-1023
Mailing address:
  • Phone: 206-939-1079
  • Fax: 206-785-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT WIENER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 206-939-1079