Provider Demographics
NPI:1427009596
Name:WISE, MICHAEL ALAN (OTR)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:WISE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 RIO PINAR DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3707
Mailing Address - Country:US
Mailing Address - Phone:386-290-9383
Mailing Address - Fax:
Practice Address - Street 1:495 S NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8470
Practice Address - Country:US
Practice Address - Phone:386-677-4300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1161225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist