1992012876 NPI number — MRS. STACEY CATHERINE WISIOROWSKI LCSW

Table of content: MRS. STACEY CATHERINE WISIOROWSKI LCSW (NPI 1992012876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992012876 NPI number — MRS. STACEY CATHERINE WISIOROWSKI LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISIOROWSKI
Provider First Name:
STACEY
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUMPHREY
Provider Other First Name:
STACEY
Provider Other Middle Name:
CATHERINE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992012876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1251
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIHUE
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96766-5251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-639-9359
Provider Business Mailing Address Fax Number:
808-245-9818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2970 KELE ST
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
LIHUE
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96766-1823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-639-9359
Provider Business Practice Location Address Fax Number:
808-245-9818
Provider Enumeration Date:
09/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW-3103 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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