Provider Demographics
NPI:1124834791
Name:WISTH, ALEXANDRIA (LPC)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:WISTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4044 ERNST DR
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-9584
Mailing Address - Country:US
Mailing Address - Phone:262-224-0966
Mailing Address - Fax:
Practice Address - Street 1:385 WILLIAMSTOWNE STE 204
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2323
Practice Address - Country:US
Practice Address - Phone:262-224-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11516-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health