Provider Demographics
NPI:1023199643
Name:WISE, JAMES HOWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:HOWARD
Last Name:WISE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:H
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:14300 GALLANT FOX LN
Mailing Address - Street 2:SUITE 211
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4003
Mailing Address - Country:US
Mailing Address - Phone:301-262-2828
Mailing Address - Fax:301-262-2828
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:SUITE 211
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-262-2828
Practice Address - Fax:301-262-2828
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00788103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD344601800Medicaid
MD344601800Medicaid
R48846Medicare UPIN