Provider Demographics
NPI:1376185553
Name:WISE, DENISE M (LPT)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 FRANKLIN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-6922
Mailing Address - Country:US
Mailing Address - Phone:254-754-0375
Mailing Address - Fax:254-754-2667
Practice Address - Street 1:5100 FRANKLIN AVE STE C
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6922
Practice Address - Country:US
Practice Address - Phone:254-754-0375
Practice Address - Fax:254-754-2667
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1109668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist