Provider Demographics
NPI:1912483561
Name:WISTERIA COUNSELING LLC
Entity type:Organization
Organization Name:WISTERIA COUNSELING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:MLADC
Authorized Official - Phone:603-729-7979
Mailing Address - Street 1:322 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03276-5037
Mailing Address - Country:US
Mailing Address - Phone:603-729-7979
Mailing Address - Fax:
Practice Address - Street 1:322 W MAIN ST # 111
Practice Address - Street 2:
Practice Address - City:TILTON
Practice Address - State:NH
Practice Address - Zip Code:03276-5037
Practice Address - Country:US
Practice Address - Phone:037-297-9796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty