NPI Code Detail JSON Logo

1083377980 NPI number — BRYAN R WISDOM LMFT

NPI Number: 1083377980
Health Care Provider/Practitioner: BRYAN R WISDOM LMFT

Information about “1083377980” NPI (BRYAN R WISDOM LMFT) exists in 1083377980 in HTML format HTML  |  1083377980 in plain Text format TXT  |  1083377980 in PDF (Portable Document Format) PDF  |  1083377980 in an XML format XML  formats.

NPI Number : 1083377980 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1083377980",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WISDOM",
    "FirstName": "BRYAN",
    "MiddleName": "R",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "LMFT",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "928 N MAIN ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "ELKHART",
    "MailingAddressStateName": "IN",
    "MailingAddressPostalCode": "46514-2736",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "859-402-3795",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "233 FULTON ST E STE 28",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "GRAND RAPIDS",
    "PracticeLocationAddressStateName": "MI",
    "PracticeLocationAddressPostalCode": "49503-3262",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "616-228-9244",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "10/18/2021",
    "LastUpdateDate": "07/17/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "106H00000X",
        "TaxonomyName": "Marriage & Family Therapist",
        "LicenseNumber": "4101007405",
        "LicenseNumberStateCode": "MI",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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