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General NPI Number Information
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NPI Number | 1598505513
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Entity Type | Individual
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Provider Name | MICHELLE WISE GENDUSA LICSW
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Gender | Female
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Dates
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Enumeration Date | 05/28/2024
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Last Update Date | 01/26/2025
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Provider Practice Location Address
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Address Line | 3546 W GREYSTONE DR.
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City | FAYETTEVILLE
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State | AR
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Zip | 72764
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Country | US
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Telephone | 509-434-6386
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Fax |
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Provider Business Mailing Address
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Address Line | 3546 E GREYSTONE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72764-6860
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Country | US
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Telephone | 870-230-0238
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LW60479720
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 22926-C
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License Number State | AR
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