=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992012876
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY CATHERINE WISIOROWSKI LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2010
-----------------------------------------------------
Last Update Date | 07/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2970 KELE ST SUITE 109
-----------------------------------------------------
City | LIHUE
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96766-1823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-639-9359
-----------------------------------------------------
Fax | 808-245-9818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1251
-----------------------------------------------------
City | LIHUE
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96766-5251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-639-9359
-----------------------------------------------------
Fax | 808-245-9818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW-3103
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------