Provider Demographics
NPI:1043833239
Name:WISE LIVING LLC
Entity Type:Organization
Organization Name:WISE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FIDAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:443-801-8848
Mailing Address - Street 1:1401 LA BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:408 ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4252
Practice Address - Country:US
Practice Address - Phone:410-567-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty