Provider Demographics
NPI:1497299150
Name:WISE, LYNDSAY BROOKE
Entity Type:Individual
Prefix:
First Name:LYNDSAY
Middle Name:BROOKE
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNDSAY
Other - Middle Name:BROOKE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4806 CENTER BROOK CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9196
Mailing Address - Country:US
Mailing Address - Phone:573-424-4190
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5275
Practice Address - Country:US
Practice Address - Phone:573-814-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002004063225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist