Provider Demographics
NPI:1083170062
Name:WISE, SIMON (COTA)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 STEVENS CT
Mailing Address - Street 2:
Mailing Address - City:SOMERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08083-3007
Mailing Address - Country:US
Mailing Address - Phone:469-396-3214
Mailing Address - Fax:
Practice Address - Street 1:110 W WISSAHICKON AVE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1802
Practice Address - Country:US
Practice Address - Phone:215-836-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing