Provider Demographics
NPI:1417047168
Name:WISE, SONDRA LYNN (LSW)
Entity Type:Individual
Prefix:MS
First Name:SONDRA
Middle Name:LYNN
Last Name:WISE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6324
Mailing Address - Country:US
Mailing Address - Phone:217-525-1064
Mailing Address - Fax:217-525-1651
Practice Address - Street 1:710 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6324
Practice Address - Country:US
Practice Address - Phone:217-525-1064
Practice Address - Fax:217-525-1651
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490132621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical