Provider Demographics
NPI:1992499339
Name:WISNASKY, MARLENA FAYE
Entity type:Individual
Prefix:
First Name:MARLENA
Middle Name:FAYE
Last Name:WISNASKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4243 S PERADOTTI RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-4543
Mailing Address - Country:US
Mailing Address - Phone:618-670-6067
Mailing Address - Fax:
Practice Address - Street 1:15455 CONWAY RD STE 117
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2022
Practice Address - Country:US
Practice Address - Phone:636-675-7566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health