Provider Demographics
NPI:1083127021
Name:WISE, JULIET LATANYA (LICSW)
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:LATANYA
Last Name:WISE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 GRIZZARD RD NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35810-3640
Mailing Address - Country:US
Mailing Address - Phone:256-658-3457
Mailing Address - Fax:
Practice Address - Street 1:2700 FAIRBANKS ST NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-2432
Practice Address - Country:US
Practice Address - Phone:256-281-1737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1325-3911C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical