Provider Demographics
NPI:1548791775
Name:WISEMAN, MARISA (BCBA)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 OFANTO ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-1798
Mailing Address - Country:US
Mailing Address - Phone:702-816-7059
Mailing Address - Fax:
Practice Address - Street 1:5550 W FLAMINGO RD STE C5
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-0137
Practice Address - Country:US
Practice Address - Phone:702-816-7059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLBA0313103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst