Provider Demographics
NPI:1275394793
Name:WISE PSYCHOLOGY SERVICES, INC.
Entity Type:Organization
Organization Name:WISE PSYCHOLOGY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:415-226-6154
Mailing Address - Street 1:1108 TAMALPAIS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3247
Mailing Address - Country:US
Mailing Address - Phone:415-226-6154
Mailing Address - Fax:
Practice Address - Street 1:1108 TAMALPAIS AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3247
Practice Address - Country:US
Practice Address - Phone:415-226-6154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700058294Medicaid