Provider Demographics
NPI:1255664348
Name:WISE, STEVEN L (PSYD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:L
Last Name:WISE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GLEN COVE PL
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3637
Mailing Address - Country:US
Mailing Address - Phone:904-994-0997
Mailing Address - Fax:
Practice Address - Street 1:482 JACKSONVILLE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3812
Practice Address - Country:US
Practice Address - Phone:904-247-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4575103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical