Provider Demographics
NPI:1003131723
Name:WISE, ELIZABETH (CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 E PARHAM RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-2743
Mailing Address - Country:US
Mailing Address - Phone:804-672-8588
Mailing Address - Fax:804-672-8587
Practice Address - Street 1:4102 E PARHAM RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-2743
Practice Address - Country:US
Practice Address - Phone:804-672-8588
Practice Address - Fax:804-672-8587
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004050235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist