Provider Demographics
NPI:1558194167
Name:WYSONG, TRISTA (LAC)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:WYSONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:HILL CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67642-1732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:939 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3608
Practice Address - Country:US
Practice Address - Phone:316-263-8807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01895101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)