Provider Demographics
NPI:1124176227
Name:WISZINCKAS, EVELYN (PHD)
Entity type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:
Last Name:WISZINCKAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CENTER STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615
Mailing Address - Country:US
Mailing Address - Phone:907-486-0311
Mailing Address - Fax:907-486-4006
Practice Address - Street 1:104 CENTER STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-486-0311
Practice Address - Fax:907-486-4006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical