Provider Demographics
NPI:1063695419
Name:WYSSMANN, JAMES WILLIAM (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WILLIAM
Last Name:WYSSMANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6692
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-752-0677
Mailing Address - Fax:
Practice Address - Street 1:1949 SUGARLAND DR STE 218
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5765
Practice Address - Country:US
Practice Address - Phone:307-752-0677
Practice Address - Fax:307-674-1825
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY403103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125548700Medicaid