Provider Demographics
NPI:1558507327
Name:WISE, LISA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:509 HALEVY DR
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1011
Mailing Address - Country:US
Mailing Address - Phone:516-302-7850
Mailing Address - Fax:516-568-7026
Practice Address - Street 1:509 HALEVY DR
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1011
Practice Address - Country:US
Practice Address - Phone:516-302-7850
Practice Address - Fax:516-568-7026
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005317-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist