Provider Demographics
NPI:1013410398
Name:WISE, ANNA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EXECUTIVE PARK DR NE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2206
Mailing Address - Country:US
Mailing Address - Phone:404-727-4592
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:12 EXECUTIVE PARK DR NE STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-727-4592
Practice Address - Fax:330-678-3677
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004597103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health