Provider Demographics
NPI:1043790660
Name:WISE, KARLISSA RENEE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:KARLISSA
Middle Name:RENEE
Last Name:WISE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:KARLISSA
Other - Middle Name:RENEE
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:707 LINDEN GROVE PL APT 203
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2598
Mailing Address - Country:US
Mailing Address - Phone:410-507-7213
Mailing Address - Fax:
Practice Address - Street 1:6700 ALEXANDER BELL DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2105
Practice Address - Country:US
Practice Address - Phone:410-507-7213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MD209831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical