Provider Demographics
NPI:1285025759
Name:WISEMAN, MA, CCC-SLP, HOLLEY
Entity Type:Individual
Prefix:
First Name:HOLLEY
Middle Name:
Last Name:WISEMAN, MA, CCC-SLP
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 1:494 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1470
Mailing Address - Country:US
Mailing Address - Phone:740-369-3650
Mailing Address - Fax:740-369-0812
Practice Address - Street 1:494 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1470
Practice Address - Country:US
Practice Address - Phone:740-369-3650
Practice Address - Fax:740-369-0812
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP11327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2095254Medicaid