Provider Demographics
NPI:1083190227
Name:WISE, LAWRENCE (HIS)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BIRCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4189
Mailing Address - Country:US
Mailing Address - Phone:931-709-0661
Mailing Address - Fax:931-709-0661
Practice Address - Street 1:1230 WEST AVE STE 101
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4080
Practice Address - Country:US
Practice Address - Phone:931-707-9543
Practice Address - Fax:931-707-9543
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN915237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist