Provider Demographics
NPI:1225488059
Name:WISE-HOWARD, TESSA
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:WISE-HOWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 12TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-6003
Mailing Address - Country:US
Mailing Address - Phone:831-883-3030
Mailing Address - Fax:
Practice Address - Street 1:299 12TH ST STE B
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-6003
Practice Address - Country:US
Practice Address - Phone:831-883-3030
Practice Address - Fax:831-883-3032
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker