MEDICARE: MARY D WISECUP MSW, LCSW

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	C009565	NC

General Provider Information

NPI Number	:	1487051561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY D WISECUP MSW, LCSW

Provider Business Mailing Address
First Line	:	57 WANCHESE RD S APT 102
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28411-8510
Country	:	US
Telephone Number	:	703-587-4457
Fax Number	:	252-594-9108

Provider Business Practice Location Address
First Line	:	720 N 3RD ST STE 101
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-3474
Country	:	US
Telephone Number	:	910-632-2191
Fax Number	:	919-251-7859

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

Provider Enumeration Date	:	12/04/2014
Last Update Date	:	10/28/2025

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