Basic Information
| Provider Information | |||||||||
| NPI: | 1457587958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISSER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 347 MIDWAY BLVD. | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403245701 | ||||||||
| FaxNumber: | 4403249978 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 MIDWAY BLVD. | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403245701 | ||||||||
| FaxNumber: | 4403249978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6023 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.