Provider Demographics
NPI:1598505513
Name:WISE GENDUSA, MICHELLE (LICSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WISE GENDUSA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3546 E GREYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6860
Mailing Address - Country:US
Mailing Address - Phone:870-230-0238
Mailing Address - Fax:
Practice Address - Street 1:3546 W GREYSTONE DR.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72764
Practice Address - Country:US
Practice Address - Phone:509-434-6386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2025-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW604797201041C0700X
AR22926-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical