Provider Demographics
NPI:1396414744
Name:DR. ELIZABETH WISE LICENSED CLINICAL SOCIAL WORKER INC.
Entity Type:Organization
Organization Name:DR. ELIZABETH WISE LICENSED CLINICAL SOCIAL WORKER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PSYD
Authorized Official - Phone:310-422-2047
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
Practice Address - Country:US
Practice Address - Phone:310-422-2047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255833125Medicaid