Basic Information
| Provider Information | |||||||||
| NPI: | 1053905752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISEMAN | ||||||||
| FirstName: | KENNETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2844 COLOMA ST | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956674406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306269240 | ||||||||
| FaxNumber: | 5306268992 | ||||||||
| Practice Location | |||||||||
| Address1: | 838 BEACH COURT | ||||||||
| Address2: | |||||||||
| City: | LOTUS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2021 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1420310221 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.