Provider Demographics
NPI:1578566451
Name:WISE, SHELLEY D (DC)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:D
Last Name:WISE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 CROSSROADS BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-8650
Mailing Address - Country:US
Mailing Address - Phone:831-373-0985
Mailing Address - Fax:831-620-0711
Practice Address - Street 1:245 CROSSROADS BLVD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923-8650
Practice Address - Country:US
Practice Address - Phone:831-373-0985
Practice Address - Fax:831-620-0711
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20443111N00000X
CAR1318520818101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7703084230006OtherCIGNA
CADC0204430OtherBLUE SHIELD
CA770308423OtherBLUE CROSS
CAT92566Medicare UPIN
CADC0204430Medicare ID - Type Unspecified