Provider Demographics
NPI:1255833125
Name:WISE, ELIZABETH L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:L
Last Name:WISE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, PSYD
Mailing Address - Street 1:PO BOX 6750
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN CLUB
Mailing Address - State:CA
Mailing Address - Zip Code:93222-6750
Mailing Address - Country:US
Mailing Address - Phone:310-422-2047
Mailing Address - Fax:
Practice Address - Street 1:2500 CEDARWOOD DR.
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN CLUB
Practice Address - State:CA
Practice Address - Zip Code:93222-6750
Practice Address - Country:US
Practice Address - Phone:310-422-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA759841041C0700X
CA99104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255833125OtherOTHER
CA75984Medicaid