Provider Demographics
NPI:1922837129
Name:WISBERGER, KEITH PATRICK (PRS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:PATRICK
Last Name:WISBERGER
Suffix:
Gender:M
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CROSS STREET
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1026
Mailing Address - Country:US
Mailing Address - Phone:330-996-9141
Mailing Address - Fax:
Practice Address - Street 1:150 CROSS STREET
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1026
Practice Address - Country:US
Practice Address - Phone:330-996-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005211175T00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist