Provider Demographics
NPI:1407504939
Name:WISE CCC
Entity Type:Organization
Organization Name:WISE CCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:JOANN
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC-S
Authorized Official - Phone:940-627-1618
Mailing Address - Street 1:1650 S FM 51 STE 400
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3630
Mailing Address - Country:US
Mailing Address - Phone:940-627-1618
Mailing Address - Fax:940-393-0429
Practice Address - Street 1:1650 S FM 51 STE 400
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3630
Practice Address - Country:US
Practice Address - Phone:940-627-1618
Practice Address - Fax:940-393-0429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health