MEDICARE: MRS. DIANE CASSODY WISEMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3532	OK
2	101Y00000X	Counselor	3532	OK

General Provider Information

NPI Number	:	1396072351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE CASSODY WISEMAN

Provider Business Mailing Address
First Line	:	8810 S YALE AVE STE P
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-3551
Country	:	US
Telephone Number	:	918-855-1435
Fax Number	:	918-626-1388

Provider Business Practice Location Address
First Line	:	8810 S YALE AVE STE P
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-3551
Country	:	US
Telephone Number	:	918-855-1435
Fax Number	:	918-626-1388

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2009
Last Update Date	:	03/12/2025

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