MEDICARE: DR. DENISE KAY WISWELL PH.D.

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	1041C0700X	Clinical Social Worker	6801018098	MI
2	103TC0700X	Clinical Psychologist	6301010069	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	U006 107001882102	OTHER	UT	INTERMOUNTAIN HEALTH CARE
2	U003 942938348DEW	OTHER	UT	EDUCATORS MUTUAL
3	U002 898470	OTHER	UT	DESERET MUTUAL

General Provider Information

NPI Number	:	1407832546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENISE KAY WISWELL PH.D.

Provider Business Mailing Address
First Line	:	901 HOPKINS AVE
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-3330
Country	:	US
Telephone Number	:	989-317-3717
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 S CRAPO ST
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-2941
Country	:	US
Telephone Number	:	989-772-5938
Fax Number	:

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

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	05/16/2013

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