Provider Demographics
NPI:1417971342
Name:WISE, MARGUERITE KAY (MS)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:KAY
Last Name:WISE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E WASHINGTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4404
Mailing Address - Country:US
Mailing Address - Phone:260-482-2586
Mailing Address - Fax:260-471-5949
Practice Address - Street 1:205 E WASHINGTON CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-4404
Practice Address - Country:US
Practice Address - Phone:260-482-2586
Practice Address - Fax:260-471-5949
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000653A101YM0800X, 106H00000X, 101Y00000X
IN33000819A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor