Provider Demographics
NPI:1568863165
Name:WISE, CHARLES AFTON (MA LMHC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:AFTON
Last Name:WISE
Suffix:
Gender:M
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 GOULD PLACE
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765
Mailing Address - Country:US
Mailing Address - Phone:407-366-5656
Mailing Address - Fax:407-386-6658
Practice Address - Street 1:1491 EAST SR 434
Practice Address - Street 2:SUITE 104
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708
Practice Address - Country:US
Practice Address - Phone:407-366-5656
Practice Address - Fax:407-386-6658
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3981101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor