Provider Demographics
NPI:1952957342
Name:WISENER, SHANNON BROOKE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:BROOKE
Last Name:WISENER
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 1:39 MARLA LN
Mailing Address - Street 2:
Mailing Address - City:EAST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02536-5057
Mailing Address - Country:US
Mailing Address - Phone:415-847-7385
Mailing Address - Fax:
Practice Address - Street 1:39 MARLA LN
Practice Address - Street 2:
Practice Address - City:EAST FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02536-5057
Practice Address - Country:US
Practice Address - Phone:415-847-7385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health