Provider Demographics
NPI:1215485917
Name:WISEMAN, REBECCA (LCSW-R)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11977-1514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11977-1514
Practice Address - Country:US
Practice Address - Phone:631-942-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054943-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY81-3814404Medicare PIN