Provider Demographics
NPI:1447896550
Name:WISNER, EVAN CRAIG (LLMSW)
Entity type:Individual
Prefix:MR
First Name:EVAN
Middle Name:CRAIG
Last Name:WISNER
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-8837
Mailing Address - Country:US
Mailing Address - Phone:269-908-0119
Mailing Address - Fax:
Practice Address - Street 1:560 MEADOW LN
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-8837
Practice Address - Country:US
Practice Address - Phone:269-908-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-24
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801104507104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801104507OtherMICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS - BOARD OF SOCIAL WORK