=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154462455
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT P. WISSORE LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 S INTERSTATE DR
-----------------------------------------------------
City | SIKESTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-472-3400
-----------------------------------------------------
Fax | 573-472-2937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | ROUTE 1 BOX 28
-----------------------------------------------------
City | MARQUAND
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-866-2767
-----------------------------------------------------
Fax | 573-472-2937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 000577
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------