Provider Demographics
NPI:1023017100
Name:WISE, BABETTE
Entity Type:Individual
Prefix:
First Name:BABETTE
Middle Name:
Last Name:WISE
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:PO BOX 418407
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8407
Mailing Address - Country:US
Mailing Address - Phone:703-558-1544
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-687-8678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3006241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R24736Medicare UPIN
DC000R59G64Medicare PIN