Provider Demographics
NPI:1063661312
Name:WISE, RAQUEL MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:RAQUEL
Middle Name:MARIE
Last Name:WISE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4645 BELPAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3602
Mailing Address - Country:US
Mailing Address - Phone:330-493-4210
Mailing Address - Fax:330-493-4744
Practice Address - Street 1:2484 W STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-5608
Practice Address - Country:US
Practice Address - Phone:330-829-2338
Practice Address - Fax:330-829-2376
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA - 07048225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant