Provider Demographics
NPI:1417721630
Name:WISE MIND AND BODY, LLC
Entity Type:Organization
Organization Name:WISE MIND AND BODY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:631-512-9807
Mailing Address - Street 1:142 NIMS SPRING DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-6461
Mailing Address - Country:US
Mailing Address - Phone:631-512-9807
Mailing Address - Fax:
Practice Address - Street 1:142 NIMS SPRING DR
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-6461
Practice Address - Country:US
Practice Address - Phone:631-512-9807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-08
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty