Provider Demographics
NPI:1417612383
Name:WISE, EDWARD LOWELL III (MA, QMHS-3)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LOWELL
Last Name:WISE
Suffix:III
Gender:M
Credentials:MA, QMHS-3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3099 SULLIVANT AVE STE H
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1800
Mailing Address - Country:US
Mailing Address - Phone:614-371-2303
Mailing Address - Fax:800-905-9950
Practice Address - Street 1:3099 SULLIVANT AVE STE H
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1800
Practice Address - Country:US
Practice Address - Phone:614-371-2303
Practice Address - Fax:800-905-9950
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral