Provider Demographics
NPI:1235989856
Name:WISE, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:WISE
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 1:320 CALLE RAYO
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-3212
Mailing Address - Country:US
Mailing Address - Phone:415-866-9411
Mailing Address - Fax:
Practice Address - Street 1:2141 PALOMAR AIRPORT RD STE 350
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1451
Practice Address - Country:US
Practice Address - Phone:415-866-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician