Provider Demographics
NPI:1396183471
Name:WISE, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:WISE
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 1:9715 HEALTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3500
Mailing Address - Country:US
Mailing Address - Phone:410-629-6148
Mailing Address - Fax:
Practice Address - Street 1:9715 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3500
Practice Address - Country:US
Practice Address - Phone:410-629-6148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT00269224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant