Provider Demographics
NPI:1508190844
Name:WISE, ELIZABETH (SPEECH ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:SPEECH ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72682-0610
Mailing Address - Country:US
Mailing Address - Phone:870-429-9127
Mailing Address - Fax:
Practice Address - Street 1:1410 POST OAK RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-5516
Practice Address - Country:US
Practice Address - Phone:870-424-0187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR05-0077Medicaid